How Topical Compounding Has Worked For My Patients
- Allen Jacobs DPM FACFAS
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You may have noticed the increasing presentation of the subject of topical compounded medications at our podiatry meetings. The reason for this is that the science of topical pharmaceutical compounding has advanced significantly over recent years.
Topical compounding allows the local delivery of high doses of medication to an area of pathology. Examples include the treatment of Achilles tendinosis, plantar fasciitis or following an acute injury. This technique provides the delivery of medications locally at levels significantly higher than with the administration of the same medications given systemically, typically as orals. In addition, the utilization of topical compounded medications provides for lower systemic levels of the same medication administered orally, generally less than 5 percent of the serum levels when one administers the same medications systemically. Furthermore, given the low systemic levels of the medications when administered topically, drug interactions are far less likely to occur.
Topical compounded medications expand the ability of the podiatric physician to effectively treat a variety of problems commonly encountered in daily practice. Many podiatric physicians are reluctant to utilize systemic medications for fear of adverse sequella or drug interactions, as a result denying some patients optimal efforts at pain relief or the reduction of inflammation. In addition, topically compounded medications are frequently accepted by the "I am already taking too many medications" patient and the "needle phobic" patient.
A particular aspect of topical compounded medications is the fact that they are medication(s), allowing me to combine multiple agents with multiple mechanisms of action. As a result, my ability to provide a patient with pain relief is substantially greater.
Take the case of inferior heel pain. Variously referred to as plantar fasciitis, plantar fasciopathy or plantar fasciosis, components of pathology may include inflammation, scarring, fibromatosis type histologic changes, irritation or compression of the medial plantar nerve or first branch of the lateral plantar nerve, tarsal tunnel compression, bursitis or osseous edema/inflammation.
Typically, I employ a topical compounded medication with a nonsteroidal anti-inflammatory drug (NSAID) (usually ketoprofen or flurbiprofen (Ansaid, Pfizer)), a topical anesthetic (typically lidocaine or bupivacaine) and verapamil, in addition to all of the usual therapeutics one would employ to treat inferior heel pain. This gives me a better chance of resolving the pain for which the patient is seeking relief.
Another example is that of symptomatic diabetic neuropathy. Here again, many podiatric physicians are reluctant to utilize antidepressants, anti-seizure medications or opioid analgesics. However, one may apply these same medications, such as gabapentin (Neurontin, Pfizer), clonidine (Catapres, Boehringer Ingelheim) or ketamine in combination topically, not infrequently reducing patient symptoms while averting adverse side effects.
Many patients presenting to our offices are under care for problems such as hypertension, reflux, congestive heart failure and renal disorders, and are on anti-coagulant therapy. Although we may desire to utilize NSAID therapy for such patients, their concurrent medical conditions or drug therapy typically preclude the use of these agents systemically. The topical application of NSAIDs, however, provides a safe and very effective alternative for the treatment of common problems such as Achilles tendinosis, plantar fasciitis or hallux limitus with osteoarthritis.
Can Topical Compounding Have An Impact In Wound Care?
Wound healing represents another area of significant potential for use of topical compounded medications. It is my belief that we as a profession have become "product bound." In other words, we debride and offload wounds, and then try to determine what "product" we should apply. Rather, we should be "process bound," asking what the wound requires.
From a histologic and physiologic standpoint, there is overlapping within each wound of the so-called stages of wound healing. Utilizing compounding for wound management, I can determine what ingredients are necessary to enhance wound healing and have them all incorporated as individual prescriptions for each patient to meet his or her individual needs.
As an example, one can mix a debriding agent (e.g. collagenase, (Santyl, Healthpoint)) with an agent to increase vascular perfusion (e.g. nifedipine, pentoxifylline (Trental, Sanofi Aventis)) with an antibiotic or antiseptic (e.g. mupirocin, metronidazole (Flagyl, Pfizer)) with something to stimulate cell growth (e.g. phenytoin (Dilantin, Pfizer)), and so forth. Furthermore, I can utilize such agents to enhance the effectiveness of various grafting techniques, e.g. Dermagraft (Shire Regenerative Medicine), Apligaf (Organogenesis), Primatrix (TEI Biosciences), etc.
What About Compounded Topical Combinations For Nail And Skin Disorders?
Finally, topical compounded medications are helpful for the management of nail and skin disorders. Rather than being restricted to the preset components of available dermatologic preparations, I can determine what each patient requires and incorporate that into my compounded medication. For example, for heel keratosis, I can utilize a keratolytic (e.g. salicylic acid or urea), an antifungal (e.g. itraconazole (Sporanox, Janssen Pharmaceuticals), terbinafine (Lamisil, Novartis) or fluconazole (Diflucan, Pfizer)), tea tree oil, agents synergistically improved antifungal azoles (e.g. ibuprofen) and so on.
The utilization of topical compounding medications is commonplace in my practice and has proven to be a benefit in relieving patient pain when I use it adjunctively with normal therapies.
The most common adjunctive applications in my office have been for:
• plantar fasciitis
• Achilles tendinopathy
• tendonitis, including posterior tibial tendon disorder
• interdigital neuroma
• plantar plate rupture
• dorsal nerve entrapment syndromes
• symptomatic neuropathy
• diabetic, venous and arterial ulceration management
When prescribing these agents, I explain to the patient that I can provide thorough compounding multiple mechanisms of action. I tell the patient that in a sense I am "cheating." However, we want to remember that the patient wants pain relief. It is essential to remember that in general, the use of these agents is adjunctive in nature and I do not abandon other traditional and appropriate treatment modalities. I inform patients that compounding is associated with less systemic risk than the same medications administered systemically. It reminds me of the philosophy of Steve Smith, DPM, philosophy on bunion surgery, “The patient wants it to look good and to feel good.”
Topical compounding has been a significant benefit to patient care in my practice. I would suggest that you look into this opportunity to better treat many of your patients with reduced likelihood of adverse reaction and increased efficacy of treatment.