Pharmacy Times

COMPOUNDINGHOTLINE

Author: Martin A. Erickson, III, RPh

Q A physician asked whether I could recommend alternative therapy for fibromyalgia.

A Here is Part 1 of my answer. Part 2 will appear next month.

The term fibromyalgia indicates inflammation of fibrous tissue (ligaments, tendons, muscles, etc). Pain, sometimes spasm, often is expressed in the base of the skull, neck, shoulders, chest/thorax, lower back, and upper legs/thighs. The syndrome appears mainly in women and can be induced or exacerbated by stress: cold or damp environment, mental or emotional trauma, sleep disorder, physical trauma, or an infection such as Lyme disease. Approximately 5% of the population is affected by this syndrome, with a diagnostic ratio of women to men of ~8:1.

Because emotional and physical stressors often are triggers for the syndrome, pharmacists can recommend alternative therapies, such as meditation/yoga providers, massage therapists, nutritionists (some pharmacists have nutrition backgrounds and can provide the service). Chronic or recurrent and acute pain can lead to depression, sleeplessness, anxiety, and a number of other symptoms, and the pharmacist can play a key role in these patients' therapies. Because the application of heat, stretching exercises, and sleep aids can be beneficial, the community pharmacist is well situated to provide adjunctive devices.

OTC pharmacologic treatments include vitamin and mineral supplementation specific to the patient's nutritional deficiencies, amino acid, antioxidant, magnesium, calcium, and other supplements that may include herbal and homeopathic remedies. Digestive support, especially for concomitant irritable bowel and related conditions, also is important.

Occasionally, OTC nonsteroidal anti-inflammatory drugs (oral or topical) can relieve the pain of fibromyalgia. Sleep aids taken only at bedtime and not during the waking hours can help with poor sleep, a common cause as well as a result of the syndrome.

The compounding pharmacist can recommend a number of alternative approaches to treatment to relieve the pain of this condition. Generally, the topical approaches often seen for relief of other neuropathic pain conditions are beneficial, not only as to pain relief, but for reduction of side effects, especially gastrointestinal ones, when these agents are administered orally. It is important to tailor these preparations to the patient's needs. When the preparations contain penetration enhancers (PEs), clinical evidence indicates that the active drugs are more efficacious than traditional ointments, such as petrolatum, cold creams, and vanishing creams because the stratum corneum is affected by the PE to facilitate absorption. Examples of such enhanced bases include pluronic lecithin organogel (PLO; Polox 20% and Lipoil), vanishing cream with PE (such as Pentravan, Lipovan, or Lipoderm), and a variety of pharmacy-specific formulations, although the latter are falling into disuse in favor of the Polox/Lipoil, Pentravan, and Lipovan-type commercially prepared combinations.

Location of pain receptors can influence choice of medication for analgesia. Various medications for analgesia are classified with respect to action: N-methyl-D-aspartate (NMDA); calcium channel antagonists (eg, ketamine, dextromethorphan, haloperidol); glutamate antagonist (eg, gabapentin); ?-amino-3- hydroxy-5-methyl-4-isoxazole propionic acid (AMPA) antagonists (eg, gabapentin, carbamazepine, phenytoin); ?-2 agonist (eg, clonidine); norepinephrine reuptake inhibitors (eg, tricyclic antidepressants); ?-1 antagonists (eg, prazocin); GABA-? agonists (eg, baclofen); and non-NMDA calcium channel blockers (eg, nifedipine).

A rational approach to therapy includes one of the NMDA antagonists, because these receptors have a pivotal role in pain sensation. Ingredients from other categories can have a synergistic effect because of the different modes of action and/or types of receptors affected. Therefore, the addition of gabapentin specifically (glutamate agonist and AMPA antagonist) can be a useful second ingredient. Following this addition, one might include an agent with ?-2-agonist, ?-1-antagonist, or GABA-?-agonist activity; others may be included as the patient's condition indicates.

The following is a sample formula encountered frequently in treatment regimens for patients with fibromyalgia. Equipment needed includes beakers, graduated cylinders, spatulas, ointment slab, balance with weights as needed, syringes, and connectors. (When ethanol, water, ethoxy diglycol, propylene glycol, or another agent is used to wet the powders, use only enough to make a paste; do not attempt to dissolve the powders in the levigating agent. The PLO system [Lipoil and Polox] can be replaced by Pentravan or another vanishing cream with PE, as indicated.)

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Mr. Erickson is director of professional affairs at Gallipot Inc.