Getting Custom Work Done at the Pharmacy
By Jeanie Lerche Davis
July 23, 2001 -- Just past his 40th birthday, Peter was taking pretty high doses of medication for his arthritis pain. They left him constipated, with a chronically upset stomach. Not a great way to live.
"He came into my store saying 'I'm nauseated, I haven't been able to sleep good, I'm a big bicyclist, but I don't even feel like doing that anymore,' " says Jonathan Marquess, PharmD, CDM, owner of Woodstock Pharmacy in suburban Atlanta.
Thus began Peter's entrée into the world of compounding -- the hand mixing of custom-made medications. A formulation for the pain medication was readily available; using pure chemicals, Marquess produced the same thing in a gel form.
Voila! "He rubbed it on the joints that were hurting him, his knees, his hips. Long story short -- he's now very happy biking with his club," says Marquess.
Reviving an Ancient Custom
Compounding harkens back to the days of mortar and pestle, to the very origins of the pharmacy profession. The practice nearly became lost during the last half-century, when the bulk of drugs became mass-produced in a one-dose-fits-all approach.
And for most people, one-dose-fits-all works just fine, says Marquess. Only in the past decade or so have pharmacists and physicians begun to realize the need for custom-made medications still exists.
"We're the medication problem solvers," Marquess tells WebMD. "Not every patient needs us. Most patients have no idea this is possible."
The art and science of compounding "is clearly accepted" by the industry's leaders, like the American Pharmaceutical Association, says spokeswoman Susan Winckler.
"When the commercially available medication is not appropriate for the patient -- when the medication a patient needs is simply not available -- that's when we need compounders," she tells WebMD. "It's one of the primary responsibilities of a pharmacist, to provide the patient with the appropriate medication."
And managed care and insurance providers are reimbursing patients for this service. "Many, many insurance companies are covering these medications," says Marquess. In fact, a compounded preparation sometimes saves money for both insurers and patients.
Gummy Bears, Lollipops, Piña Coladas, and More
As in Peter's case, most medications can be transformed into various forms like gels, creams, liquids, suppositories, or capsules -- even a "gummy bear" that can be sucked or chewed rather than swallowed.
Patients with arthritis or cancer, as well as paraplegics, quadriplegics, and stroke patients, are among the many who benefit from having pain and nausea medications custom-made into these different forms.
As with Peter, sometimes side effects like sleepiness, stomach upset, or constipation are the problem, says Marquess. "A cream or gel can really help in those cases. The medication gets absorbed a little faster [because it's applied right to the site]; it also bypasses the intestinal tract and the liver."
Does your child abhor the taste of his headache medicine? Giving medications great flavors -- chocolate, raspberry, banana, piña colada -- are also the compounder's specialty. Flavoring can be added to a commercially prepared medication, too, says Marquess.
Compounders can even make medicated lollipops.
"Instead of a dentist giving a shot of Novocain to a child, they'll give them a little [medicated] lollipop while they're in the waiting room, so it numbs their mouth while they're sitting there," Marquess tells WebMD.
Fluffy or Fido won't take their medications? Compounders can tempt them with tuna, chicken, beef flavors, and more. In fact, an entire veterinary compounding niche has developed around treating both large and small animals, says Marquess. Rabbits get a special concoction of boiled celery and parsley. Ferrets love banana-cream-flavored chewies. Squirrels like fruity flavors. Monkeys favor raspberry.
Fewer Side Effects With Precise Dosages
The standard dosage of a medication is a problem for some people. "With some medications, with some people, standard dosages can cause side effects," he tells WebMD. "We fine-tune the dosage, prepare the exactly what the patient needs."
Case in point: Natural hormone replacement therapy -- meaning that it is identical in structure to the hormone produced in the body -- is a popular request at Marquess' pharmacy, and is available only through compounding pharmacies. The off-the-shelf formulation of synthetic estrogen works for many women, "but not for every woman," he says.
"We can tailor the estrogen dose for the patient," says Marquess. "She gets the exact amount of hormone that she needs, based on the doctor's prescription. And because it is a precise dosage, she has fewer side effects."
Both doctor and patient are important in this process, he says. "The patient might be saying, 'I'm still having some symptoms, some hot flashes.' The doctor can increase or decrease the amount of hormone that woman may receive." Because the pharmacist is mixing it from chemicals, he can customize it to a capsule or cream form.
Finding a Compounding Pharmacist
There are thousands of compounders in the U.S. To find one, check with any independent pharmacy in your local community. "They will likely be a compounder or be able to tell you where there is one," says Marquess. "In the U.S., independents fill more compounded prescriptions than chain pharmacies do."
You might also check with your doctor, says Jim Smith, a spokesman for Professional Compounding Centers of America. "More than likely, your physician is going to be working with a pharmacist they're used to getting good results from."
PCCA is one of the few companies that provide training, bulk chemicals, a library of prescription formulations, and technical consultation for compounders. "This is a network of the leading problem-solving pharmacists in North America," he says. PCCA also offers scholarships to pharmacy students in 60 of the 83 pharmacy schools across the country.
"Pharmacists are really conscientious people anyway; they know where their skills are," Smith tells WebMD. "Our mission is to beef up their skills, give them a level of competency and confidence in what they're doing."
Supplier companies like PCCA "do a good job making sure pharmacists are using high-quality materials. And that's important," Winckler tells WebMD. "You have to work with reputable suppliers in the compounding business, just as you have to work with reputable suppliers in the prepared medications business."
Choose your pharmacist carefully, just as you choose your physician, she advises. "As with anything, talk to the people behind the counter, make sure you feel comfortable with them."
Whether a medication is mass-produced or hand-mixed, "if it appears different from the last time you saw it, ask your pharmacist, Winckler tells WebMD. "We try to have error-proof systems, but frankly that's impossible."
Indeed, what of the quality of these hand-mixed medications? They are not FDA regulated, as are mass-produced Glaxo or Merck medications. State boards of pharmacy and state boards of medicine regulate compounding pharmacies, says Winckler. "I would argue that provides more protection for the consumer than were the FDA to regulate it," she tells WebMD.
In a compounding pharmacy, either the pharmacist or a pharmacy technician -- standing within five feet of the pharmacist -- will be doing the work, she says.
"It's Wonder Bread vs. the corner bakery," Winckler tells WebMD. "You should know that the pharmacist and physician have put more time into that preparation, to make sure it is tailored for you."
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