SEPTEMBER 01, 2004
Martin A. Erickson, III, RPh

QI am not a pharmacist, but a patient. My problem is that I have food intolerances to gluten, corn, soy, and dairy. My disease is microscopic colitis. Ingesting as little as a molecule will make me sick for 48 hours. See for more information. I need 2 things, an antidepressant (Prozac works, but contains corn) and a pain reliever. I am in contact with many others with my disease, and none of us have been able to find a source for drugs that we can tolerate. I would appreciate any information you might be able to give me.

AThis column usually refers patients with questions to the patient's local pharmacist. A question from a patient this month raised an important issue, however.

The patient, who has colitis, requires an analgesic and an antidepressant containing no ingredients chemically related to or derived from gluten, soy, corn, and dairy products because of her gastrointestinal (GI) intolerance to these items. This patient belongs to an Internet group of patients with similar intolerances, all of whom are unable to find suitable dose forms for prescribed therapies.

The situation presents important opportunities for the pharmacist who can compound antidepressant and analgesic capsules, suspensions, suppositories, tablet triturates, etc that contain none of the potentially offending products. For example, rice starch can substitute for lactose or starch USP (which may be of corn or wheat derivation) when compounding capsules; vegetable-origin (tree material?ask for documentation) capsules are available for use when a concern arises about animal products.

Suppositories and tablet triturates can be compounded to avoid the products to which the patient is intolerant. Common bases are fatty acid blends and cocoa butter that melt at body temperature to release the drug and water-soluble bases such as polyethylene glycol (PEG) blends and gels that release drug as they dissolve when exposed to body fluids.

The patient mentioned above could benefit greatly from capsules compounded with acetaminophen, morphine sulfate, or any of a wide range of analgesics and capsules compounded with amitriptyline or other antidepressant available as active bulk powders. Some commonly-used excipients, in addition to rice starch, that are not related to the offending groups include calcium carbonate USP, microcrystalline cellulose NF and kaolin USP. Magnesium stearate, often used as a glidant, can be used as a capsule excipient. Dextrose NF and dextrin NF can be derived from starch: a potential hazard for the above patient.

The question also emphasizes the importance of patientpharmacist interaction and collaboration. Cogent questions and professionally-directed interviews can provide a means to ensure efficient, appropriate delivery of therapy. Many criticallyconsidered, well-developed methods for patient consultation are found in pharmacy literature and should be implemented as an integral part of pharmacy compounding, which, because it combines consultation and specific patient dose forms, is the epitome of pharmaceutical care.

The "allergy" category requires question and distinction: chronic medical conditions and intolerances are often incorporated into this category and thus improperly communicated to other professionals involved in a patient's care. For example, if a patient reports Morphine Sulfate GI distress as "allergy" and is not questioned about symptoms related to the report, the incorrectly recorded "allergy" can have long-term effects on the patient's therapy. The patient's record should reflect not only true allergies, but also intolerances and her/his chronic medical condition. Electronic and automated systems are rapid, convenient methods of communication, but the pharmacist should examine the information provided with a professionally critical eye to ensure complete and correct recording. Clear, complete information allows the widest range of therapeutic choices and possibilities for excellent patient care. The information provided by this patient allows an opportunity for the local pharmacist to "make a difference" in her quality of life.

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