Palliative Care
The goal of palliative care is to provide the best possible quality of life for patients and their families. Palliative care is “the active, total treatment of patients whose disease is not responsive to curative treatment.” Symptom control involves therapies for pain management, nausea & vomiting, dry mouth & stomatitis, excessive pulmonary secretions/death rattle, radiation mucositis and proctitis, and wound care.
Per a prescription order, a formulation can be compounded to contain the proper combination of active ingredients, in the most appropriate base, to treat a specific type of wound. We customize medications to meet each individual’s specific needs.
For example, the choice of cream, ointment, or gel can be clinically significant. Each time a wound needs to be cleaned, there is the potential for disruption of new tissue growth. Gels, which are more water soluble than creams or ointments, may be preferable for wound use because a gel can be rinsed from the wound by irrigation. Ointments may contain polyethylene glycol (PEG), which can be absorbed from open wounds and damaged skin. If the wound is quite large and too much PEG is absorbed, it can lead to renal toxicity.
Another useful dosage form is the “polyox bandage” – which can be puffed onto a wound and will adhere even if exudate is present. A polyox bandage can be compounded to contain the active ingredient(s) of your choice.
The following list is just a few of the preparations that we can compound for palliative care. All formulations are customized per prescription to meet the unique needs of each patient. Please call us to discuss the dosage form, medication, and strength which are most appropriate for your patient.
- ABHR: gel and troche
- Cholestyramine ointment
- Dextromethorphan: single agent and oral modified release preparations
- Hydrocodone without acetaminophen
- Lidocaine – Tetracaine spray
- Metoclopramide: nasal spray and suppository
- Misoprostol: suppository and oral preparations
- Morphine transdermal
- Pilocarpine: gel, lollipop, or oral modified release preparations
- Promethazine gel
- Scopolamine gel
- Short chain fatty acid enemas
- Sucralfate oral adhesive paste, cream, and enema.
Orally administered anti-emetics can be difficult for a nauseated child to “keep down,” and rectal suppositories may not be well accepted by children. Even persistent nausea can often be effectively controlled by using a combination of medications tailored to meet an individual’s specific needs. Dosage forms include transdermal gels, suppositories, lollipops, and more.
Promethazine is commonly compounded for topical or transdermal application to treat nausea, vomiting, and vertigo, but this preparation may be used as an antiemetic for cases ranging from chemotherapy to motion sickness. The dose is typically 25mg for adults, and the dose is decreased for children. The gel is applied to an area of soft skin, such as the inside of the wrist or arm, the side of the torso, or the inside of the thigh. For children, doses are often applied to the inside of one wrist, and then the wrists are rubbed together.
US Pharmacist, August 1999; 74-5
Radiation proctitis is a known complication of radiation therapy for prostate cancer. Commercially available treatments are often ineffective and have focused on relieving symptoms after damage has occurred, although options exist for prevention.
A prospective, randomized, placebo-controlled, double-blinded trial concluded that misoprostol rectal suppositories significantly reduce acute and chronic radiation proctitis symptoms in patients receiving radiation therapy for prostate cancer.
Am J Gastroenterol 2000 Aug;95(8):1961-6
Seven patients with radiation proctitis completed an open pilot study to evaluate the effectiveness of short chain fatty acid (SCFA) enemas. Four weeks of treatment resulted in clinical improvement in all patients, and modest changes in endoscopic and pathological parameters.
Am J Gastroenterol. 1996 Sep;91(9):1814-6
Topical sucralfate may induce a lasting remission in a majority of patients with moderate to severe rectal bleeding due to radiation proctosigmoiditis.
Excessive Secretions/Death Rattle
Difficulty clearing upper airway secretions (death rattle) is a problem for half of all dying patients. Treatment often includes the use of anticholinergic drugs, such as scopolamine (also known as hyoscine) or atropine. Transdermal scopolamine has several indications for symptom control in patients with end-stage disease: control of excess salivary secretions, management of terminal secretions, and control of nausea.
There are many factors that can interfere with the ability to eat when a person is receiving chemotherapy. Malnutrition may result, yet it is often preventable. Our pharmacy can compound medications to help combat mouth tenderness and infections, which may enable patients to enjoy eating again.
Cancer. 2002 Nov 15;95(10):2230-6
A three-drug mouthwash (lidocaine, diphenhydramine and sodium bicarbonate in normal saline) can provide effective symptomatic relief in patients with chemotherapy-induced mucositis.
Support Care Cancer. 2000 Jan;8(1):55-8
Loss of saliva (xerostomia) is one of the most common complaints among patients who have received radiation therapy of the head and neck. Xerostomia contributes to radiation-induced periodontal infection, dental caries, osteoradionecrosis, and poor digestion of carbohydrates. Ask us about sialogogues (saliva stimulants) in customized dosage forms.
The following article discusses the benefits of using pilocarpine in a sustained release dosage form to treat xerostomia.
Nausea & Vomiting
Persistent nausea can often be effectively controlled by using a combination of medications tailored to meet that individual’s specific needs. Dosage forms include transdermal gels, suppositories, lollipops, and more.
Promethazine is commonly compounded for topical or transdermal application to treat nausea, vomiting, and vertigo, but this preparation may be used as an antiemetic for cases ranging from chemotherapy to motion sickness. The dose is typically 25mg for adults, and the dose is decreased for children. The gel is applied to an area of soft skin, such as the inside of the wrist or arm, the side of the torso, or the inside of the thigh. For children, doses are often applied to the inside of one wrist, and then the wrists are rubbed together.
US Pharmacist, August 1999; 74-5
Lorazepam, diphenhydramine, haloperidol, and metoclopramide (known in combination as “ABHR”) have been prepared as a rectal suppository and in other transdermal dosage forms. The rationale is to use a variety of medications which target various pathways such as vagal nerve stimulation, the vomiting center, and the CTZ for more severe cases. Researchers at Memorial Sloan-Kettering Cancer Center have studied the antiemetic activity and safety of the antiemetic regimen of metoclopramide, dexamethasone, and diphenhydramine in patients receiving standard outpatient chemotherapy programs. Vomiting was prevented in over 70% of patients.
Intranasal metoclopramide may significantly reduce the frequency of acute vomiting in patients receiving highly emetogenic chemotherapy, such cisplatin-induced delayed emesis. Intranasal metoclopramide caused minor irritation of the nasal membrane and unpleasant taste in some patients, but was otherwise well tolerated, with no report of serious extrapyramidal effects.