Case Studies of 
Compounded Prescriptions 
By working together with physician and patient, compounding pharmacist Chuck Fulmer has been able to meet the specific needs of these patients.  These are some of the many success stories of Partners In Care.  These reports are not claims of efficacy  for a particular product or formula.

BHRT Improves Woman’s Life
MF (fictitious name) a 48-year-old female was referred to Partners In Care to evaluate her current hormone therapy and its relationship to her symptoms. She presented in tears saying that her husband was going to leave her. She had no libido. She was experiencing vaginal dryness which made any attempt at relations uncomfortable. She had sleep disturbances, fatigue and had memory problems and was severely depressed. She was currently on a conjugated estrogen from horses and two antidepressants (not from the same physician). While I silently consider her current therapy and thought about my recommendations to the physician, she anxiously asked are you going to tell me there is no help for me? I reassured her, I was just organizing my thought before I call her physician. I asked how long have you been like this? The reply shocked me “since I had my hysterectomy when I was 28.”

My recommendation to her physician was Bi-Estro 50% (due to previous estrogen therapy) .625mg, Progesterone 50 mg, and Testosterone 1 mg each in a separate buccal tablet. The buccal route was chosen for a faster onset of action. An Estriol (E3) vaginal cream was recommended for the vaginal dryness. The physician approved my recommendations and the prescriptions were formulated and dispensed.

When she came for her refills the following month, her physical appearance was different and she proudly announced that she was a different woman. Her mother who was accompanying her affirmed she is truly a different person. Today she is only using the Progesterone, Testosterone and Estriol vaginal cream and continues to do well.
 

Oral Neuropathic Pain
An 84-year-old female patient presented with neuropathic pain shooting from the roof of her mouth diagonally into her eye. After consulting with the physician, who did not want to use injections because of her age and just the fact they would be invasive. We decided to use a mixture of Bupivicaine, Gabapentin and Ketamine to treat her pain. I decided to use a flavored PLO gel because of its sticky nature as the vehicle and apply it under her denture. About an hour after leaving the pharmacy, the lady called and reported that 97% of her pain was gone.  This therapy continued to relieve the patient's pain for a number of years.  This case is an excellent demonstration of the working partnership of Physician, Patient and Pharmacist solving an individual’s unique problem.

Transdermal T3 & T4 Solves Patient’s Problem
JT (fictitious name) a 49-year-old female complained that she was unable to take her thyroid medications due to extreme nausea with Thyroid USP, Levothyroxine (T4) and Triiodothyronine (T3), She had even tried breaking the tablets into pieces and only taking partial doses and she still had the severe nausea. She came to Partners In Care to see if there was an alternate dose route for her thyroid. I explained some of my colleagues had prepared transdermal T3 & T4 formulations for patients but I had no idea if it would solve her problem. After consulting with her physician, we decide to start with a low strength transdermal T3 & T4 combination applied to the carotid area twice a day. Her blood levels were checked monthly. Her dose was first increased after 3 months and then adjusted up again in 3 months. The patient today has a normal and stable thyroid level with no nausea. All the symptoms of hypothyroidism have disappeared. The patient claims this formula saved her life.

Severe Cystic Acne
A physician recently called concerning a 13-year-old male with severe cystic acne. We were told the parents had exhausted all commercial treatments except isotretinoin capsules (trade name Accutane) and the parents were opposed to this due to side effects. The physician was asked if there was a hormonal component to his condition. I explained that spironolactone was used as an antiandrogen in women. To minimize the risk of system antiandrogen effect in a teenage male, I suggested a low strength topical cream with phenylephrine HCL to further reduce the possibility of system effects. The spironolactone was combined with nicotinamide and vitamin A. Three aromatic oils were used to cover the scent of the spironolactone. The patient was instructed to apply the cream at bedtime and wash off in the morning. Forty-five days after start therapy, the physician call stating that the patients face was clear. Parents of other teenagers have noticed the dramatic change in the patient’s face. They are impressed that the results were achieved with out the risk of isotretinoin capsules. 

High Dose Transdermal Ketoprofen
for Severe Reflex Sympathetic Dystrophy

By Mary Beth Wiles, M.D., Blairsville, GA
Patient History: JB (fictitious name) is a 36 yr old white male, allergic to codeine and morphine, who sustained an industrial accident to his right hand in May 1986. Electrical studies revealed bilateral carpal tunnel syndrome and entrapment of the ulnar nerves at the wrist. Results of a cervical thermogram done in February 1990 were consistent with severe bilateral RSD.

Treatment: JB subsequently received 14 stellate ganglion blocks, numerous other nerve blocks, and concurrent medication and physical therapy (including therapy at the Hand Rehabilitation Center of Atlanta) which did not appear to help.

Compounded Medication: In February 1994, JB received a prescription for ketoprofen 10% in pluronic lecithin organogel (PLO). The strength was increased to 20% the following month. In January 1995, n-decyl methyl sulfoxide was added to the 20% ketoprofen to enhance transdermal absorption. In four days, the patient returned to the pharmacy requesting a refill, and reported significant improvement in hand color and decrease in swelling. Within one month of using 120 gm of enhanced ketoprofen per week, the improvement was visually obvious. To assess the risk of toxicity with such high doses of ketoprofen, a blood level was done 5/95, and reported no detectable blood levels (consistent with the literature regarding transdermal NSAID therapy).
Pharmacokinetics of ketoprofen in man after repeated percutaneous administration.

Outcome of Therapy: Prior to beginning the ketoprofen therapy (Feb '94), JB reported a pain level of 10 on a scale of I to 10. In March 1996, he reported a pain level of 4 on bad days and 0 on good days.

Due to the successful outcome achieved by the use of high dose transdermal ketoprofen in the above case, we treated two female patients in a similar manner. Patient .A responded to enhanced ketoprofen 50% in a vanishing lecithin organogel (VLO), and used 60 gm per week. Patient B received relief with ketoprofen 30% and 0.3% dextromethorphan in VLO. These patients, who were all refractory to previous treatment, have substantially benefited from the transdermal absorption of ketoprofen. Oral administration of exceedingly high doses of ketoprofen would have been unacceptable due to the high blood levels that would have been required to achieve required tissue levels.