Chronic pain can be 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. Some of 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. Optimal treatment may involve the use of medications that possess pain-relieving properties, including some antidepressants, anticonvulsants, anesthetics, and NMDA (N-methyl-D-aspartate) antagonists such as dextromethorphan and ketamine, can block pain transmission in dorsal horn spinal neurons, reduce nociception, and decrease tolerance to and the need for opioid analgesics. By combining various agents which utilize different mechanisms to alter the sensation of pain, physicians have found that smaller concentrations of each medication can be used.
Topical and transdermal creams and gels can be formulated to provide high local concentrations at the site of application (e.g., NSAIDs for joint pain), for trigger point application (e.g., combinations of medications for neuropathic pain), or in a base that will allow systemic absorption. Side effects associated with oral administration can often be avoided when medications are used topically. Studies suggest that there are no great restrictions on the type of drug that can be incorporated into a properly compounded transdermal gel. Advantages of transdermal topical preparation are avoidance of first pass hepatic metabolism and the GI tract, may improve compliance, increased drug concentration at site of pain and decreased systemic side effects. Topical and transdermal preparations are often preferred to oral medications due to decreased systemic side effects and the avoidance of first-pass hepatic metabolism. Dosage forms include creams, ointments, and gels, solutions, and sprays.
How Compounding and Transdermal Medications May Help with the Opioid Crisis
Traditionally, opioid analgesics were reserved for a few select conditions, such as terminal illness and surgery, but more recently opioids have been readily prescribed for multiple conditions. Transdermal compounded medications are patient-specific and customizable to include different types of drugs, in various dosage strengths, that can be delivered simultaneously in one application. Due to the different origins and types of pain, treatments may be most beneficial when multiple classes of drugs with various mechanisms of action are included. In addition, combination drug therapy may include nontraditional pain management options, and can maximize therapeutic effects of medications through additive or synergistic properties, often allowing the dosage of individual drugs to be decreased. Many of the challenges faced when using oral opioid therapy may be overcome by using transdermal drug delivery since this route of administration reduces adverse effects, increases patient compliance, and limits exposure to potentially abusive drugs.
We can prepare the following (in metered-dose dispensers), based on a prescription among others:
- Ibuprofen Transdermal Gel/Cream 5-10%
- Diclofenac 5-10% Transdermal Gel/Cream
- Ketoprofen Cream/Gel 2.5-10%
- Gabapentin 5-20% Topical Gel/Cream
- Diclofenac/Lidocaine 4%/2% Cream
- Diclofenac/Baclofen 3%/2% Gel/Creams
