Introduction:

Millions of individuals across the world suffer from chronic
pain. Chronic pain can be a burden for both patients and their healthcare providers.
Optimal pain management is essential for patients to lead productive, enabling
lifestyles. Pain can arise due to a variety of different conditions, and as a
result, healthcare providers have to use many different approaches for
successful treatment.

How can compounds help?
Many medications that are traditionally used to manage symptoms of chronic pain can
cause undesirable side effects. Opioid-related medications such as codeine, hydrocodone or oxycodone can be very intolerable in the astrointestinal
system. Treating pain topically is an alternative option to avoid these undesirable side effects. Many pharmacies are able to compound topical preparations that contain various medications to help control symptoms of pain. Because these formulations are applied topically, just enough of the medication is absorbed through the skin to help relieve symptoms at the site of the pain.

Introduction
Disorders of the skin can be a problem among patients of all ages. Common problems include: scarring, acne, rosacea, skin discoloration, psoriasis, and eczema. Numerous medications exist on the market to help with these conditions but they can often be costly and many health insurance plans may not cover them.

How can compounds help?
Preparations such as gels, creams, lotions, ointments can be compounded to help manage dermatological ailments. Pharmacists will work with medical providers such as dermatologists to provide a customized topical preparation specifically designed for treating your condition at an affordable cost.

Introduction:
Hormonal imbalances can occur at any age and affect both men and women. The primary hormone in men is testosterone. As age increases, testosterone levels decline and can lead to a condition known as andropause or more commonly “low-T.” Testosterone deficiency may lead to decreased concentration, lethargy, loss of libido, erectile dysfunction, and depression among other side effects.

How can compounds help?
There are several effective products that exist on the commercial market to help with symptom management. If you have low testosterone and if the current available treatment options are not a good fit for you, your compounding pharmacies can work with your medical provider to create a testosterone formulation for you. These medications may be for oral or topical use. With proper monitoring and dosage adjustments, compounded testosterone formulations can help control symptoms associated with low-T in a safe manner.
Serious side effects have been reported with testosterone including the following:
• Blood clots in the legs or lungs. Contact your healthcare provider if you notice pain or swelling in the legs, redness of the legs, difficulty breathing, or chest pain.
• Possible increased risk of heart attack. Seek immediate medical attention if you experience symptoms of a heart attack.

Symptoms include:
• chest pain
• feeling of pressure in the chest
• shortness of breath
• discomfort in the neck, back, shoulder, or arms
• nausea/vomiting
• dizziness or lightheadedness
• sweating
• Possible increased risk of stroke. Seek immediate medical attention if you experience symptoms of a stroke.

Symptoms include:
• sudden numbness or weakness on one side of the body (can be in the face, arm or leg)
• sudden confusion
• difficulty speaking
• sudden change in vision
• sudden trouble walking (may experience loss of balance or coordination).
• Possible increased risk of prostate cancer. Your healthcare provider will check for prostate cancer before and during treatment with testosterone.
• Edema with or without heart failure. Contact your healthcare provider if you notice swelling of your ankles, feet, or body.
This is not a complete list of testosterone serious side effects. Ask your doctor or pharmacist for more information.

Compounding requires a relationship between the patient, physician, and pharmacist. Together, they will work to provide an alternative treatment option when and if the current available treatment options are not the best fit for you.

Introduction:
Hormonal imbalances can take place at any age and affect both men and women. Many women experience side effects when dealing with menopause and hormone imbalance. Unstable hormone levels can lead to chronic symptoms and disorders that can disrupt daily activity. Some of these symptoms include but are not limited to: unexpected weight gain, hot flashes, migraines, depression, difficulty sleeping, loss of libido, and fatigue.

The primary hormone of importance in females is estrogen, which exists in three different forms in the body: estrone (E1), estradiol (E2), estriol (E3). Other important hormones include progesterone (P4), testosterone, and dehydroepiandrosterone (DHEA). These substances may help restore natural balance in the body and may help alleviate chronic symptoms arising from imbalance.

How can compounds help?
There are several effective products that exist on the commercial market to help with symptom management. Compounding allows for a more personal and tailored dose for you. In addition, compounding offers a variety of dosage forms that will best fit you. By working with your medical provider, compounding pharmacies can create various formulations that may include any combination E1, E2, P4, E3, DHEA, and/or testosterone to help manage your symptoms with the lowest possible dose to alleviate symptoms for the shortest period of time.

Complete medical histories will be taken and evaluated to create a product that will help you manage any issues you might be experiencing. The amount of these hormones will be limited to mimic how they naturally exist in your body to ensure safety. Formulation examples include topical and vaginal creams, oral capsules, and orally dissolving or sublingual tablets. With sufficient monitoring, formulations can be adjusted to help relieve your most bothersome symptoms.
Compounding is a relationship between the patient, physician, and pharmacist. Together, they will work to provide an alternative treatment option when and if the current available treatment options are not the best fit for you.

Introduction:
Many medications are not available in child-friendly dosage forms. The most common factors that influence medication compliance among children include taste and appearance. The commercial market does not produce many formulations of medications that are easy to use in the pediatric population.

How can compounds help?
Compounding is an option for helping children get the medications they need in a suitable form. Many medications that may not be available in liquid forms can be compounded into solutions, suspensions, and syrups. Many of the oral alternatives can be flavored to help with medication administration in children.

Introduction
If you are like most people, you tend to take your feet for granted and forget just how important the feet are to your health and how your feet may be affected by other medical conditions you may have. With poor foot health, simply moving around, going to work, getting normal activities done can be quite challenging. Many patients suffering from medical conditions like arthritis and diabetes often suffer from foot ailments. Fortunately, podiatric physicians can help. Podiatry is the branch of medicine that deals almost exclusively with the foot, ankle and lower leg.

How can compounds help?
Compounded formulations provide innovative solutions to challenging medical situations involving the treatment of foot and leg issues.

Topical, transdermal therapy can decrease systemic exposure and significantly reduce the risk of undesirable side effects of certain medications such as drowsiness, gastrointestinal upset or bleeding.
Compatible medications can be combined into a single formulation for ease of administration.
Some compounded formulations solve nail removal problems. For example, urea plasters, a non-surgical treatment for nail removal, are less costly, essentially painless, and reduce the risk of infection or hemorrhage.
The following list is just a few of the conditions for which your pharmacist, working closely with your podiatrist, can prepare customized formulations to meet your unique needs:

• Warts
• Nail Fungus
• Heel Spurs
• Plantar Fasciitis
• Poor Circulation
• Wound Care
• Toenail Removal
• Dry Skin
• Inflammation/Arthritis
• Swelling
• Blisters
• Calluses
• Diabetic Neuropathy
• Neuropathic Sprains
• Neuritis
• Muscle Spasm
• Athete's Foot
• Sprains
• Tendonitis
• Iontophoresis/ Phonophoresis

Introduction
Compounding for proctology is the preparation of customized medication for conditions related to the anus and rectum. Conditions that involve the anus or rectum typically will cause one discomfort and pain. In addition, many available topical and systemic treatments may simply be inadequate in treating the condition. Fortunately, your pharmacist can prepare customized medications to manage your condition, and in turn, help to manage your discomfort and pain.

Hemorrhoids

Hemorrhoids (also called piles) are swollen, engorged veins within the lining of the anal canal or lower rectum. They are either inside the anus or under the skin around the anus. Internal hemorrhoids normally don’t cause much discomfort. External hemorrhoids, on the other hand, are typically painful. Both types of hemorrhoids can bleed when they are irritated.

Traditionally, hemorrhoids are associated with aging, pregnancy, chronic constipation or diarrhea, straining during bowel movements, and prolonged sitting on the toilet. These conditions interfere with blood flow to and from the area, causing it to pool and enlarge the vessels.

While bleeding, anal itching and pain are common symptoms, some people with hemorrhoids have none of these symptoms and only learn of their hemorrhoids during routine physical examinations or colonoscopy screenings. Symptoms, when they do occur, usually go away within a few days.

Simple, self-help and over-the-counter measures can ease pain and promote healing. Increased fluid and fiber intake, either by eating plenty of fruits and vegetables, or with fiber supplementation, draws water into stools, making them softer and easier to pass.

Over-the-counter topical therapies such as pads infused with witch hazel (Tucks), as well as soothing creams that contain lidocaine, hydrocortisone, or other ingredients like phenylephrine (Preparation H) are available to help you find relief. Compounded prescription preparations are sometimes necessary for more severe or thrombosed hemorrhoids.

Anal Fissures

An anal fissure is a tear in the anus. Passing hard stools, constipation, and chronic diarrhea can cause stretching and tearing of the anus. Other factors include pregnancy, childbirth and complications of Crohn's disease, ulcerative colitis or a sexually transmitted infection such as anal herpes infection.

Anal fissures cause sharp, stinging pain that can be severe and tends to worsen when you pass a bowel movement and for an hour or so after. The pain is often accompanied by bleeding during bowel movements. In most people, this skin damage will heal quickly without any problems. However, fissures sometimes become chronic because after the first tear, bowel movements reinjure the area. Some people seem to have a higher than normal pressure in the anal canal from muscle spasms of the internal anal sphincter (the muscle around the anus). Increased anal canal tone and sphincter spasm is believed to decrease blood flow to the anal region and slow the healing process. For this reason, the most effective medications for anal fissures work by increasing blood flow to the region and relaxing muscles to reduce spasms.

Compounded topical treatments such as nitroglycerin, nifedipine, and diltiazem can be prepared by your compounding pharmacist. These medications work by dilating the blood vessels around the anus, and/or by causing relaxation of the internal anal sphincter. Blood is able to flow to the area more easily to promote faster healing.



How can compounds help?
Your compounding pharmacist can prepare medications in a variety of formulations to treat and manage conditions like hemorrhoids, anal fissures, idiopathic proctodynia (pain syndrome affecting the perianal region), and/or inflammatory bowel disease such as Crohn’s disease.

In addition, your compounding pharmacist can prepare medications to manage pain post hemorrhoidectomy, which is a surgery to remove internal or external hemorrhoids. If you are receiving radiation therapy for pelvic malignancy, you may experience radiation proctitis, which is a known complication. If this is the case, your compounding pharmacist can formulate a customized treatment for you.

Introduction
Participating in any sport or fitness activity, at any level, can result in injury that may require a variety of treatments. Whatever the injury, compounded medications are available in different strengths as well as unique dosage forms to provide a personalized treatment. Compounded medications can help you get back into the game much faster and are not just for professional athletes but are available to everyone.

How can compounds help?
Compounded medications can treat pain, inflammation, muscle spasms, bacterial/fungal infections, and neuralgia. In addition, compounded medications can help treat excessive sweating, can be used for pre-game rubs, and can be used with iontophoresis and phonophoresis technologies, which are used to enhance drug penetration through the skin. Many oral medications that are traditionally used to manage sports injuries, such as non-steroidal anti-inflammatory drugs (NSAIDs), can cause undesirable side effects that can negatively affect athletic performance. However, these medications, if used topically, can ease inflammation and pain, with fewer undesirable side effects. In short, compounded sports medicines offer the ability to supply key ingredients in strengths and delivery systems that most effectively provide relief and recovery.

Introduction:
Giving a pet medications can be a struggle. Compounded medications are a simple solution for pet owners who have difficulty giving their pets medicine. We understand that your pets are a very important part of your family. A pet can suffer from a variety of medical conditions and because animals differ in their bodily systems across species, treating conditions can be difficult.

How can compounds help?
Together with veterinarians, pharmacists can provide compounded medications to expand the amount of treatment options available for veterinary conditions. Medications can be made in oral liquid, topical, and animal treat forms. These medications can be flavored to appeal to animals, making them easier to administer.

Introduction
Treating a wound or a serious injury is often a complex activity as it involves many different bodily processes to make sure a wound heals quickly and safely, without leaving lasting health issues. Specialized medications and compounded preparations may be used to aid in the treatment of many types of wounds as well as be used post surgery. Customized medication becomes important when treating wounds, because of the choice of medication as well as the formulation used (e.g., creams, ointments, gels), affects proper healing.

How can compounds help?
There are a variety of compounds that can be prepared as either creams, gels, or ointments that include special combinations of ingredients that can promote healing, remove dead tissue, relieve pain, and increase blood flow to the affected area. In some cases, a medicated wrap or bandage may be a great option for wounds healing on active parts of the body like the legs or arms.

Introduction
Chronic pain can be very difficult to manage in many patients. Many of the traditional oral drugs used for pain treatment, such as opioids, NSAIDs, and anticonvulsants, can have unwanted systemic side effects. These classes of medications, among others, can be just as effective in managing pain when used topically. Using a multimodal approach to treating symptoms of chronic pain has also been shown to be efficacious, which can be easily accomplished using a topical formulation.

Treatment Options
Classes of medications that can be used topically include: NSAIDs, Alpha II Agonists, AMPA-Na+ Channel Blockers, GABA Agonists, NMDA-Ca2+ Channel Blockers, Tricyclic Antidepressants.

Advantages:

• Avoid first pass hepatic metabolism
• Avoid GI tract
• May improve compliance
• Increased drug concentration at site of pain
• Decreased systemic side effects

Disadvantages:

• Most common side effect is rash
• May not be suitable for large areas
• Absorption may vary from patient to patient depending on the stratum corneum barrier.

Introduction
Each patient's dermatological condition is unique which can create a challenge for practitioners in regards to finding treatment options. Compounding pharmacists have the ability and experience to compound individualized therapies for numerous dermatological conditions including scarring, acne, rosacea, skin discoloration, psoriasis, and eczema.

Treatment Options
Treating these conditions often requires a multidisciplinary approach. Depending on the specific illness, a variety of drugs can be compounded into topical creams, lotions, gels, pastes, and ointments. Common agents used to compound formulations include calcium channel blockers (for circulation), anti-inflammatory agents, antihistamines, antipruritic agents, local anesthetics and many other classes of drugs.

Dermatological Conditions
Some of the conditions we help treat include:

• Acne
• Alopecia
• Athlete’s Foot
• Anesthetics
• Chemical Peels
• Diaper Rash / Incontinence
• Eczema
• Fever blisters
• Head Lice / Scabies
• Hyper-pigmentation Molluscum
• Nail fungus
• Peels
• Psoriasis
• Poison ivy
• Pruritus
• Radiation burns
• Rosacea
• Scarring and Keloids
• Shingles
• Sun Protection / Photoaged Skin / Wrinkles
• Vitiligo
• Warts

Introduction
Many men can experience andropause or low-T as they age. As a result of declining free testosterone levels in the body, males can exhibit a variety of debilitating symptoms. Decreased concentration, lethargy, loss of libido, erectile dysfunction, and depression are commonly seen in men with low-T. Low-T is often characterized by total testosterone levels falling below 300 ng/dl. Testosterone supplementation can offer a solution for these patients.

Treatment Options
Compounded topical and oral preparations are options to help patients with low-T. Many preparations are commercially available such as AndroGel, Testim, Striant. Injectable testosterone may not provide normal physiological serum levels for patients. In addition, patients may need specific dosing adjustments that may not be managed with these products. A compounded preparation could be an alternative if patients are having issues or concerns with commercially available therapy. Studies have shown that there is increased mortality specifically among patients with cardiovascular risks or history of cardiovascular issues. Complete medical histories should be taken and evaluated to ensure patient safety.

Introduction
Many women have difficulties coping with chronic conditions stemming from menopause. These conditions can often be complicated to manage. Symptoms arise from deficiency or dominance of estrogen, progesterone, or testosterone. Hormone replacement therapy involves three main forms of circulating estrogen: estrone (E1), estradiol (E2), estriol (E3). Other important hormones include progesterone (P4), dehydroepiandrosterone (DHEA), and testosterone (T).

Treatment Options
Studies have shown that combinations of E1, E2, E3, P4, and DHEA have been effective in treating various vasomotor symptoms that may be associated with menopausal hormone imbalance. Formulations include topical and vaginal creams, oral capsules and orally disintegrating tablets. Various ratios of these hormones exist in the female body, and in order to mimic these ratios, formulations often have to be compounded to contain some proportion of the three estrogens. Triestrogen or TriEst is a common name given to formulations containing E1, E2, and E3 while biestrogen or BiEst is a common name given to formulations containing E2 and E3. BiEst generally contains 80% estriol and 20% estradiol, while TriEst contains 80% estriol, 10% estrone, and 10% estradiol. A prescription written for 2.5 mg of BiEst will actually contain 2 mg of estriol (E3) and 0.5 mg of estradiol (E2) if using a conventional 80:20 ratio.

Introduction
Many medications are not available in child-friendly dosage forms. The most common factors that influence medication compliance among children include taste and appearance. The commercial market does not produce many formulations of medications that are easy to use in the pediatric population.

Treatment Options
Compounding pharmacies are able to provide clinicians with a variety of options of medication dosage forms for their pediatric patients. Common preparations are seen in liquid and topical forms. Freezer pops, gummy chews, and lollipops can be made containing different medicines depending on patient need. These medications can also be flavored according to patient preference.

Examples:

• Omeprazole suspension for reflux which is commonly seen in infants
• Topical diaper rash formulations using cholestyramine

Introduction
Sports medicine, for athletes ranging from weekend warriors to World-Class Olympians, has proven to be another area where pharmacy compounding has shown to be very useful. For example, compounded medications can be used to treat sports-related pain, inflammation, muscle spasms, bacterial/fungal infections, and neuralgia. In addition, compounded medications can can be used for pre-game rubs, and can be used with iontophoresis and phonophoresis technologies, which are used to enhance drug penetration through the skin. Compounded medications allow personalized treatment and the options are unlimited as formulations are customizable in terms of dosage, method of administration, the number of active ingredients, absorption, and more.

Treatment Options
Many preparations are commercially available to help manage pain, inflammation, and muscle spasms, but they can cause undesirable side effects. However, these medications, when used topically, can provide better therapeutic benefit with fewer unwanted side effects.

Treatment options may include:

• Topical NSAIDs such as ibuprofen
• Topical anesthetics such as LET gel (lidocaine, epinephrine, tetracaine)
• Medications for iontophoresis and phonophoresis such as steroids, dexamethasone, NSAIDS, local anesthetics, salicylates, and individual substances such as zinc oxide, iodine, acetic acid, and calcium chloride
• Medications used for pre-game rubs such as emu oil and anti-spasmodic drugs

Introduction
Veterinary medication therapy often poses unique challenges. Many medications can be compounded to help with administration and treatment of conditions in a variety of animals. Compounded preparations are always prepared from FDA-approved animal or human drugs. These preparations are prepared and evaluated in a manner consistent with current potency, purity and stability standards. Compounding pharmacies want to work with veterinarians to create specialized, effective formulations for their patients.

Treatment Options
Depending on the animal and condition, various medications can be compounded into oral liquids, topical preparations, and animal treats.

Introduction
As a provider, when treating wounds or serious injuries, you want to ensure you properly treat the wound in order to obtain the best outcomes. Customized medication becomes important when treating wounds, because the choice of medication as well as the formulation used (e.g., creams, ointments, gels) will affect the healing process.

Treatment Options
Examples of compounded medications for wound care may include:

Topical antibiotic solutions to be used during the healing process
Papain/Urea Ointment for wound debridement
Topical Phenytoin for ulcer healing
Topical compounds may include any of the following ingredients: Misoprostol, Metronidazole, Phenytoin, and Lidocaine.

Compounds may be made in a variety of combinations and may depend if there is pain and odor associated with the wound.

When Writing A Prescription for a Compounded Medication the Following Information Should be Included:
1) Patient identification (name, date of birth, address)
2) Date
3) Drug allergies
4) Indicate prescription is to be compounded
5) Generic name of all active ingredients
6) Strength or Dose of medication (for example: %, milligram, grams)
7) Formulation desired (cream, gel, troches, capsule, suppository, ODTs, etc.)
8) Quantity desired and/or days supply needed
9) Directions for use
10) Medical condition being treated
11) Refills, if any.

If you have any specific questions regarding formulations, do not hesitate to contact our pharmacy.

Questions?
Contact our pharmacists with questions. We're happy to answer any questions and discuss suitable options to meet your patient's needs.