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OTHER TOPICS -
COMPOUNDED TREATMENTS FOR PAIN

*** These are NOT listed in any order of significance ***
They are samples only

Specific formulations musty be prescribed by a doctor.  Some combinations require DEA Registration.
The Compounder pharmacists are available to discuss formulas during regular business hours:
Monday through Friday from 9:00 AM to 5:00 PM. 
The telephone is 630.859.0333 and the FAX is 630.859.0114

Muscle and Skeletal Pain

Cyclobenzaprine 10mg/ml in transdermal base (PLO); 0.5ml to 1ml tid
Diclofenac 1.5% in DMSO Lotion
Ibuprofen 20%, Piroxicam 1% in transdermal base (PLO)
Ketoprofen 3%, 5%, 10% or 20% in transdermal base (PLO)
Naproxen 10% in transdermal base

Neuropathic Pain

Amitriptyline/Baclofen in PLO
0.5%/0.5% UP to 2%/2%
Amitriptyline 2%/ Carbamazepine 2% in 70% DMSO lotion
Amitriptyline 2%/ Carbamazepine 2% in transdermal base (PLO)
Carbamazepine 2%, Cyclobenzaprine 10%, Ketoprofen 10%
Clonidine 0.2%, Gabapentin 6%, Ketamine 10% in transdermal base (PLO)
Ketamine 5%, Gabapentin 5%, Clonidine 0.2% in transdermal base (PLO)
Clonidine 0.2%, Ketamine 15% in transdermal base
Guanethidine 1% in transdermal base
Guanethidine 1%, Lidocaine 4% topical spray (for RSD)
Guaifenesin 10%, Ketoprofen 10%, Pentoxiphylline 5% (for TMJ)
Ketamine 10% Nasal Spray (1 spray in each nostril q3h)
Ketamine in transdermal base 5% to 20%
Ketoprofen 10%, Lidocaine 5% in PLO
Phenytoin 20% in PLO
Proranolol 4% in PLO

Ischemic Pain

Nifedipine 8% in PLO
Pentoxiphylline 15% in PLO

Post-Herpetic Neuralgia

Alpha Lipoic Acid, 100mg po tid x 4 months
Amitriptyline 2%, Ketoprofen 10% (for the face)
Aspirin in Chloroform (650mg/15ml)
Aspirin 5%, Lidocaine 5% in Chloroform (for the scalp)
Ketamine 10%

Algorithm for Chronic Neuropathy

1) NMDA-Ca Channel Blocker
Ketamine 5-10% in PLO, up to every 2 hours
or as a nasal spray, 10-50mg/ml, 1 - 2 sprays q3h or prn
Orphenedrine 10% in PLO
Dextromethorphan 10% in PLO (also works po at higher doses, <400mg/day)

2) AMPA-Na Channel Blocker
Gabapentin 6-10% in PLO 3 to 5 times daily
Carbamazepine 10% in PLO
Lidocaine 5-10% in PLO, up to q2hr
Mexilitine 2% in PLO

3) Alpha II Agonist
Clonidine 0.2% in PLO, TID up to q2hr

4) Substance P Blocker
MU Agonists (Morphine Sulfate, Hydrocodone, etc.)

5) GABA Agonist
Baclofen 2% in PLO TID up to q2hr

6) Tricyclic Antidepressant
Desipramine 2-10% in PLO TID, up to q2hr prn
Amitriptyline 2-10% in PLO TID, up to q2hr prn

7) Magnesium in PLO

NOTES:

1. Ketamine 10%, Gabapentin 6%, Clonidine 0.2% is a common starting regimen
2. Add Baclofen 2%, Amitriptyline 2%, Nifedipine, Opioids and Magnesium as needed
3. In allodynic post-herpetic neuralgia consider Ketamine 10%, Bupivicaine 0.5% in nasal spray - also transdermal
4. Evidence exists for NMDA receptors in the dermal/epidermal junction
5. Evidence exists Gabapentin receptors in the periphery
6. Evidence exists Adrenergic receptors in the periphery
7. Evidence exists Opioid receptors in the periphery
8. The Compounder has introduced a new dosage form, THE FOAM.  It is a special vehicle that can be combined with absorption enhancers and active ingredients.  It is light and very easy to apply.  It may be beneficial for patients who want a topical product but who have difficulty with traditional transdermal creams or gels.

PLO is Pluronic Lecithin Organogel.  It is compounded from an aqueous phase, pluronic F127, and a lipid phase, lecithin and isopropyl palmitate.  It is an excellent transdermal vehicle.

DMSO is Dimethylsulfoxide.  It has a long tradition of use as a liniment and absorption enhancer.  Older versions of DMSO smelled bad and contained impurities.  Most compounders now have access to a purified form of DMSO.  It is very pure and is almost odor free.  It retains all of the benefits of DMSO without some of the obvious difficulties.