COMPOUNDING HOTLINE
QI am not a pharmacist, but a patient. My problem is that Ihave food intolerances to gluten, corn, soy, and dairy. Mydisease is microscopic colitis. Ingesting as little as a molecule willmake me sick for 48 hours. See finerhealth.com for more information.I need 2 things, an antidepressant (Prozac works, butcontains corn) and a pain reliever. I am in contact with many otherswith my disease, and none of us have been able to find asource for drugs that we can tolerate. I would appreciate anyinformation you might be able to give me.
AThis column usually refers patients with questions to thepatient's local pharmacist. A question from a patient thismonth raised an important issue, however.
The patient, who has colitis, requires an analgesic and an antidepressantcontaining no ingredients chemically related to orderived from gluten, soy, corn, and dairy products because of hergastrointestinal (GI) intolerance to these items. This patient belongsto an Internet group of patients with similar intolerances, all of whomare unable to find suitable dose forms for prescribed therapies.
The situation presents important opportunities for the pharmacistwho can compound antidepressant and analgesic capsules,suspensions, suppositories, tablet triturates, etc that contain noneof the potentially offending products. For example, rice starch cansubstitute for lactose or starch USP (which may be of corn orwheat derivation) when compounding capsules; vegetable-origin(tree material?ask for documentation) capsules are available foruse when a concern arises about animal products.
Suppositories and tablet triturates can be compounded toavoid the products to which the patient is intolerant. Commonbases are fatty acid blends and cocoa butter that melt at bodytemperature to release the drug and water-soluble bases suchas polyethylene glycol (PEG) blends and gels that release drugas they dissolve when exposed to body fluids.
The patient mentioned above could benefit greatly from capsulescompounded with acetaminophen, morphine sulfate, orany of a wide range of analgesics and capsules compoundedwith amitriptyline or other antidepressant available as active bulkpowders. Some commonly-used excipients, in addition to ricestarch, that are not related to the offending groups include calciumcarbonate USP, microcrystalline cellulose NF and kaolinUSP. Magnesium stearate, often used as a glidant, can be usedas a capsule excipient. Dextrose NF and dextrin NF can bederived from starch: a potential hazard for the above patient.
The question also emphasizes the importance of patientpharmacistinteraction and collaboration. Cogent questions andprofessionally-directed interviews can provide a means to ensureefficient, appropriate delivery of therapy. Many criticallyconsidered,well-developed methods for patient consultation arefound in pharmacy literature and should be implemented as anintegral part of pharmacy compounding, which, because it combinesconsultation and specific patient dose forms, is the epitomeof pharmaceutical care.
The "allergy" category requires question and distinction:chronic medical conditions and intolerances are often incorporatedinto this category and thus improperly communicated toother professionals involved in a patient's care. For example, ifa patient reports Morphine Sulfate GI distress as "allergy" andis not questioned about symptoms related to the report, the incorrectlyrecorded "allergy" can have long-term effects on thepatient's therapy. The patient's record should reflect not only trueallergies, but also intolerances and her/his chronic medical condition.Electronic and automated systems are rapid, convenientmethods of communication, but the pharmacist should examinethe information provided with a professionally critical eye toensure complete and correct recording. Clear, complete informationallows the widest range of therapeutic choices and possibilitiesfor excellent patient care. The information provided bythis patient allows an opportunity for the local pharmacist to"make a difference" in her quality of life.
E-mail your compounding questions tocompounding@pharmacytimes.com
Mr. Erickson is director of professional affairs at Gallipot Inc.
