Do you or someone you know have problems swallowing?  Dysphagia (difficulty or discomfort in swallowing) is a problem for many people, especially stroke victims, the elderly and people with advanced dementia. Difficulty with swallowing oral medications increases the risk of aspiration (breathing in a foreign object or sucking food or the medication into the airway) which can lead to pneumonia. Also, hospice and palliative care patients often develop complications such as impaired gastrointestinal absorption, nausea, vomiting, delirium, or cognitive impairment, all of which would complicate the ability to take required oral medications. These are some of the reasons why alternative routes of administration, including transdermal or rectal, can be very helpful.  

Transdermal preparations are applied topically and absorbed through the skin. If a patient has fluctuating or declining liver function, transdermal administration may be advantageous because transdermal meds do not need to pass through the liver before being absorbed, like oral medications do. Transdermal medications can be compounded to treat pain and inflammation, spasms, and nausea/vomiting.

Ask our compounding pharmacist for more information. We are happy to answer your questions and work together with physicians, patients and their families to compound the most appropriate medication, strength and dosage form for each patient. Bring us your medication problems!

Consultant Pharmacist. 2016 June; 31(6):313-9.

This newsletter discusses a subject that is difficult for many women and health care professionals to talk about openly, yet in a recent study in a U.S. urban area was reported by almost 7% of women aged 18-64 years. Women should not suffer needlessly.  It’s a problem we can help with customized medications.

The problem is vulvodynia, defined as chronic pain in the area around the opening of the vagina (vulva) for which there is no identifiable cause. Vulvodynia can occur in women of any age. The burning or sharp knife-like pain, tingling or itching, or pain on contact can lasts for 3 months or longer, and can be debilitating. Pain or discomfort is typically only on one side and may be most pronounced while sitting, and least prominent when lying down.

The study revealed that only 3% of women meeting vulvodynia criteria were actually diagnosed with vulvodynia. Most women remain undiagnosed following multiple physician visits. Physicians such as dermatologists, urologists, and gynecologists are largely unfamiliar with chronic vulvar pain not attributable to a specific disorder such as herpes genitalis, lichen planus, cancer (e.g. squamous cell carcinoma), or neurological disease (e.g. postherpetic neuralgia).

Often, even with thorough testing, no obvious cause can be identified, and ongoing chronic vulvar pain becomes a true mental and physical burden for affected women.

In a substantial proportion of women, pain can be relieved with appropriate doses of prescription medications including tricyclic antidepressants, serotonin-noradrenaline reuptake inhibitors, pregabalin, and compounded topical gabapentin cream.

Contact our compounding pharmacist to confidentially discuss this or other problems. Our compounding pharmacists work together with physicians and their patients to customize medications based on each patient’s unique needs. We welcome your questions.

Reference: J Pain Res. 2015; 8: 845-849.

As men age, testosterone levels gradually decline. And, low testosterone levels (clinically termed hypogonadism) lead to decreased well-being, increased risk of cardiovascular disease, loss of muscle, increased risk of Type 2 diabetes and other metabolic syndrome diseases, reduced sexual function, and bone loss.

Benefits of testosterone replacement therapy (TRT) are clearly established: improved sexual function, increase in lean muscle mass and strength, mood and cognitive function, with possible reduction in frailty and osteoporosis. However, recently some questions have arisen regarding the risk of heart attack and stroke in men receiving TRT.

The cardiovascular issues associated with TRT have been clarified by recent studies showing clearly that increased testosterone levels are associated with reduced mortality. Studies reporting increased risk have been flawed designs with inadequate baseline diagnosis and follow-up testing. An extensive review of the testosterone replacement therapy literature reveals that the majority of clinical studies show that properly administered testosterone replacement therapy, in which estradiol and dihydrotestosterone levels are also controlled, does not increase the risk of cardiovascular events. And, more good news: there is no evidence that TRT is associated with increased risk of prostate cancer or symptomatic benign prostatic hyperplasia.

Testosterone replacement therapy should be monitored, and when needed, an aromatase inhibitor such as anastrazole should be added to control estradiol levels that tend to increase with testosterone therapy; as well as an a 5α-reductase inhibitor, such as dutasteride or finasteride to control dihydrotestosterone (DHT) levels.

At the recommendation of the National Association of Boards of Pharmacy, we suggest that patients should always seek medical attention immediately if symptoms of a heart attack or stroke are present, such as:

• Chest pain
• Shortness of breath or trouble breathing
• Weakness in one part or one side of the body
• Slurred speech

Testosterone therapy is available in many forms, and transdermal preparations that are applied to the skin are quite popular. Creams are easy for the patient to use and many health care professionals and patients prefer daily administration of testosterone to long-lasting pellets and injections.

Another option is compounded troches, which offer these benefits:

• Decreased risk of cross contamination, i.e., men need not be concerned about others contacting the site of application, such as the arm or leg when a child or pet is held.
• Rapid buccal or sublingual absorption means the dose can reduced compared to that required for transdermal forms of testosterone.
• Patients can quickly achieve peak levels when desired.

Our compounding pharmacists work together with physicians and their patients to customize medications by prescription based on each patient’s unique needs. We welcome your questions.

Ther Adv Urol. 2016 Apr;8(2):147-60.

Aging Male. 2015;18(4):205-6.

Int J Pharm Compd. 2015 May-Jun;19(3):195-203.

Topical and transdermal pain formulations are very popular among health care providers and patients, but unfortunately, not all doctors are familiar with how to best prescribe customized medications. Topical and transdermal preparations are often preferred to oral medications due to decreased side effects and the avoidance of initial breakdown of drug by the liver (first pass metabolism). Dosage forms include creams, ointments, and gels; medication sticks; solutions, and sprays.

“Topical” and “transdermal” are not interchangeable terms. Transdermal medications are applied topically but not all topical medications are absorbed through the skin and enter the bloodstream to have effects elsewhere in the body. The extent of absorption is dependent on the base and compounding technique. Transdermal preparations can create a greater systemic effect than topical preparations.

Diabetic Neuropathy

Compounded topical creams can play an outstanding role in meeting the needs of patients with diabetic neuropathy-associated pain. A recent study showed good to excellent results in relief of pain associated with diabetic neuropathy and relief of other chronic neuropathic pain with the use of compounded creams. Use of the creams resulted in a reduction in the need for oral analgesics and referrals made by physicians to pain specialists.

We will work together with you and your health care provider to customize medications that meet your unique needs. We typically suggest starting with lower doses and one to two drug combinations and adjusting the dose and choice of medications based on each patient’s response.

Testosterone therapy is increasingly used to treat symptoms of hormone deficiency in pre and postmenopausal women. Testosterone is essential for physical and mental health in women as well as men. Although frequently thought of to increase sex drive, testosterone’s role in sexual function is only a small part of its physiologic effect in women. Receptors for testosterone are located in almost all tissues including the breast, heart, blood vessels, gastrointestinal tract, lung, brain, spinal cord, peripheral nerves, bladder, uterus, ovaries, endocrine glands, vagina, skin, bone, bone marrow, muscle and fat.

Testosterone declines gradually with age in both sexes. Pre and post-menopausal women, and aging men, may experience symptoms of testosterone deficiency including anxiety, irritability, depression, lack of well being, physical fatigue, bone loss, muscle loss, memory loss, insomnia, hot flashes, rheumatoid complaints, pain, breast pain, urinary complaints, incontinence and sexual dysfunction. According to Rebecca Glaser, MD and Constantine Dimitrakakis, MD, PhD: testosterone is not masculinizing and does not increase aggression or cause hoarseness; testosterone does increase scalp hair growth, is mood stabilizing, and is cardiac and breast protective.

A source of confusion concerning the safety of testosterone therapy in both men and women is the extrapolation of adverse events from high doses of oral and injectable synthetic anabolic steroids to therapy using the bio-identical form of testosterone in doses that simply restore normal physiologic levels. Bio-identical testosterone is the same substance that is naturally produced by the human body. In England and Australia, testosterone is licensed and has been used in women for over 60 years. In the United States and Canada, compounding pharmacies can customize testosterone in doses that are appropriate for women.

Ask our compounding pharmacist for more information about testosterone and other bio-identical hormones. We work together with practitioners and patients to create hormone balance, and have successfully relieved symptoms in patients who have not responded to or who have experienced intolerable side effects using commercially-available hormones.