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PRESENT Podiatry Online CME & Conferences | Custom Therapy Options in the Modern Podiatry Practice 8/26/18, 9)50 PM
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Residency Education / General Medicine
Custom Therapy Options in the Modern Podiatry Practice

Emil Haldey, PharmD
Emil Haldey, PharmD gives a brief overview of what a compounding pharmacist is and what types of
medication they are capable of creating. Mr Hadley reviews many different conditions that can be treated
by compounding medication not only in podiatry, but in all areas of medicine. Additionally he discusses the
advantages of compounding medications and different forms of medication administration available.
CME (Credits: 1)
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1. Complete the Pre-Test
2. View the Lecture
3. Complete the Quiz (Min. 70% Passing Score)
4. Complete the program Survey
Goals and Objectives
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1. Define compounding
Complete the Pre-Testand Discuss the advantages of compounding
2. Highlight the conditions in which custom therapies can be utilized

View the Lecture
3. Review methods
Complete of(Min.
the Quiz administration for compounding
70% Passing Score) preparations
4. Discuss
Completecommon conditions
the program Surveyand compounding considerations
5. Discuss clinical case studies
Accreditation and Designation of Credits

1. Define compounding and Discuss the advantages of compounding
2. Highlight the conditions in which custom therapies can be utilized
CME (Credits:
3. Review 1)
methods of administration for compounding preparations
This lecture has

4. Discuss been approved
common conditionsfor
andthe PRESENT Podiatric
compounding Education Online curriculum by the Council of
considerations
Teaching Hospitals Residency Education Review Committee.
5. Discuss clinical case studies
Release Date: 01/01/2016 Expiration Date: 12/31/2018
Author
(Credits: 1)
CME
This lecture has been approved for the PRESENT Podiatric Education Online curriculum by the Council ofPage 3 of 12
https://podiatry.com/lecturehall/description/4500/Custom-Therapy-Options-in-the-Modern-Podiatry-Practice
Teaching Hospitals Residency Education Review Committee.

Emil Haldey, PharmD
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Lecture Transcript
biomedical
Male Speaker: device manufacturers,
It's becoming a littleormore
otherpopular
corporations whose products
in our profession or services
and one are related
that we need a lot oftoeducation
the subjecton
matter
is compounding. Compounding materials that are usually applied topically for various conditions that can of
of the presentation topic. The intent of this policy is not to prevent a speaker with a potential conflict
interest from making a presentation. It is merely intended that any potential conflict should be identified openly
promote some type of medication, whether it's reduction of pain, inflammation, et cetera. Obviously, we need
so thattothe
to go listeners outside
a specialist may formof their own judgments
our profession about
to assist us the presentation
in this with
educational the fullOur
process. disclosure
next talkofisthe facts.
going to
be
--- given by two physicians, one is Dr. Haldey, who is a pharmacist who knows the profession of pharmacy very
well. He has worked for numerous
has nothing companies, including Parke-Davis Pfizer and Boehringer Ingelheim
to disclose.
Emil Haldey
Pharmaceuticals. In addition, we will be hearing from Dr. Akhtar, who is a practicing podiatric physician, dealing
in wound care and specializing in trauma. He is working at the Hyperbaric and Wound Care Center at Saint
Joseph in Paterson in Wayne New Jersey. So, please welcome Dr. Haldey and Dr. Akhtar.
[Applause]
Male Speaker: It's becoming a little more popular in our profession and one that we need a lot of education on
is compounding. Compounding materials that are usually applied topically for various conditions that can
Dr. Emil Haldey: Good morning everyone. Thank you so much for having us here. My commitment to you is this.
promote some
We're going type of
to have funmedication,
today. We'rewhether
going toit'slearn
reduction
aboutof pain, inflammation,
compounding. et cetera.
But also, Obviously,
regardless of yourwe need
familiarity
to gocompounding,
with to a specialist Ioutside of our
guarantee profession
you, to assist
you will walk awayus in this
with educational
a few process. Our
pearls of information next
that talkbe
you'll is ready
going to
to
be
usegiven
comesbyMonday
two physicians, oneinisyour
or Tuesday Dr. Haldey,
clinical who is a pharmacist
practices. Are you guyswhoseeing
knowsthe theslide
profession
on the of pharmacy
screen here? very
well.
Great,He has worked
thank for numerous
you. Today, companies,
what are our including
objectives? Parke-Davis
We'll define Pfizer and
compounding. Boehringer
We’ll Ingelheim of
discuss advantages
Pharmaceuticals. In addition, we will be hearing from Dr. Akhtar, who is a practicing podiatric physician, dealing
compounding. In addition, we'll highlight various conditions and disease states in which custom therapies can
in
bewound
used. Icare and specializing
will review methods ofin administration
trauma. He is working at the Hyperbaric
for compounding. and
We'll also Wound
talk aboutCare Center atconditions
the common Saint
Joseph in Paterson
and various in Wayne
compounding New Jersey.Lastly,
consideration. So, please welcome
Dr. Akhtar Dr. Haldey
will finish and Dr.
with some Akhtar.
clinical case studies. First, let's
talk about compounding and what it is. Got it. Thank you. Let's go to the definition of compounding. It's an art
[Applause]
and science of preparing customized medications. Let’s dissect it. Art and science, just like medicine, science
because everything a good compounding pharmacist does is evidence-based, very, very important.
Dr. Emil Haldey:
Customized Good morning
medications everyone.
for individual Thankbased
patients you so
onmuch for having us
the prescriber’s here. My commitment
specifications. A very keytoelement
you is this.
We're
here isgoing to have
individual fun today.
patients basedWe're going specifications.
on doctor to learn about We'll
compounding.
talk more But
aboutalso, regardless
it. It’s of as
important yourwefamiliarity
learn
with compounding, I guarantee you, you will walk away with a few pearls of information that you'll
about compounding, we dissect it and realize what it is. How many of the doctors here speak or read Russian? be ready to
use comes
We have Monday
some? ThisorisTuesday
a copy ofinayour clinical practices.
prescription Areinyou
that I found my guys
familyseeing the slide
files written by on
mythe screen here?
grandfather
Great, thank you. Today, what are our objectives? We'll define compounding. We’ll discuss advantages of
physician back in the Soviet Russia from 30 plus years ago. The reason I show it to you, number one, this is
compounding.
near and dear to In my
addition,
heart. we'll highlight
Number various conditions
two, compounding and disease
has been states
around for in which
ages. custom
Just like therapies
medicine, can
it's been
be used. I will review methods of administration for compounding. We'll also talk about the common conditions
and various compounding consideration. Lastly, Dr. Akhtar will finish with some clinical case studies. First, let's
talk about compounding and what it is. Got it. Thank you. Let's go to the definition of compounding. It's an art
and science of preparing customized medications. Let’s dissect it. Art and science, just like medicine, science
because everything a good compounding pharmacist does is evidence-based, very, very important.
around as a scientific tool for many, many years. In early 1900s, as pharmaceutical industries started getting
momentum, compounding started taking a nose dive. But the last 20 years or so, compounding has seen
resurgence due to the technology, and also a number of patients asking and requesting information about it.
What is a compounding pharmacist? Who is a compounding pharmacist? Every time you talk to one of us, we
make it a point to specify it to you, we are a compounding pharmacist. We're not just a regular pharmacist, we
are compounder. Why do we do that? Why are we so proud? Well, we look at ourselves as innovators, as
solution, as problem solvers. As I go through this presentation, I will share a lot of examples with you
throughout various fields of medicines. Not to educate you about dentistry or gynecology, but rather to impress
upon you the possibilities of compounding, because the possibilities are endless. What's the difference
between compounding and manufacturing? Well, with manufacturing, you have no specific patient in mind
when the drug is produced. Doctors matching patients to their product available. With compounding, we’re
around
making as
theaformula
scientific
totool for the
match many, manyThat's
patient. years.the
In early 1900s, as pharmaceutical industries started getting
key difference.
momentum, compounding started taking a nose dive. But the last 20 years or so, compounding has seen
resurgence
[04:59] due to the technology, and also a number of patients asking and requesting information about it.
What is a compounding pharmacist? Who is a compounding pharmacist? Every time you talk to one of us, we
make
If you it a point toback
remember specify it todefinition
to the you, we are
thataI compounding
shared with you,pharmacist.
individual We're notindividual
patient, just a regular pharmacist,
prescriber. That's we
the
are compounder. Why do we do that? Why are we so proud? Well, we look at ourselves
key difference between compounding and manufacturing. A well-trained compounding pharmacist always as innovators, as
solution,
functionsas problem
within solvers.
the triad of careAs Iwhere
go through this apresentation,
you have I will and
patient, a doctor shareaa lot of examples
pharmacist. What's with
theyou
goal in
throughout various fields of medicines. Not to educate you about dentistry or gynecology,
compounding? Well, the goal is really to solve the problem and to improve therapeutic outcomes. I always but rather to impress
tell
upon you the possibilities of compounding, because the possibilities are endless. What's the difference
doctors when I speak to doctors, the goal is to deliver the right drug to the right place of action. If you need a
between compounding
different dose, and manufacturing?
dosage form Well,not
or medication that's with manufacturing,
commercially you have
available, we no
canspecific patient
do it. For in mind
example, if you
when the drug is produced. Doctors matching patients to their product available. With compounding,
have a child who cannot swallow a pill, we can deliver that medication to them in the liquid form. If you have awe’re
making the that's
medication formula to match
available in the patient.
tablet That's
form but the looking
you’re key difference.
to deliver it to your patient in suppository form, a
compounding pharmacist can do that. If you need a combination product or sustained-release product, we can
[04:59]
do that as well. For example, many of you may be familiar with transdermal formulations, combining various
drugs from different therapeutic classes, obviously done by a company pharmacist. If your patient needs to
If you dyes
avoid remember back to the adefinition
or preservatives, few monthsthat ago,
I shared
I gotwith you,
a call individual
from patient, individual
a pain management doctorprescriber.
telling meThat's the
that my
key difference
patient between
is allergic compounding
to parabens. and has
The patient manufacturing. A well-trained
been responsive compounding
to Lidoderm, Lidoderm pharmacist
patches, butalways
now has
functions
developed an allergic reaction. Can you compound something similar to that? First of all, I said, “Thank in
within the triad of care where you have a patient, a doctor and a pharmacist. What's the goal you
compounding? Well, the goal is really to solve the problem and to improve therapeutic outcomes.
doctor. I didn’t know Lidoderm had parabens, so I learned something.” We went back to the data and looked I always tellat
doctors
the creamwhen I speak
basis to doctors,
that had the goal
no parabens. is to deliver something
I compounded the right drug for to
thattheparticular
right place of action.
patient, so theIf you need
patient a
could
different dose,
tolerate the dosageand
medicine formgetorthe
medication that's not
clinical benefits. commercially
What available,
are the service areas? weI'llcan do it.
make For example,
it easy if you
for you. Virtually,
have
everyafield
child
ofwho cannotstarting
medicine, swallowfroma pill, we canpain
podiatry, deliver that medication
management, to them
physical in theand
medicine liquid form.allIfthe
rehab, youway
have a
medication that's available
down to neurologist sports in tablet form
medicine, even but you’re looking
dentistry. to deliver
We'll discuss someit toofyour patient in suppository
the therapeutic areas and form,
go a
compounding pharmacist Let's
through this presentation. can do that.
talk aboutIf you
painneed a combination
management first. product or sustained-release
Well, it offers product,
you alternative routes of we can
do that as well. AFor
administration. lotexample,
of times, many
when of you
you may
talk be familiar
to pain with transdermal
management formulations,
doctors, they also work combining various
within hospice care.
drugs from different therapeutic classes, obviously done by a company pharmacist.
I'll throw some examples out to you from hospice care. Let's see how a patient who is nauseous and If your patient needs to
avoid dyes orvomiting.
experiencing preservatives, a few
One of months ago,
the common I got
drugs a call
used for from
nauseaa pain
andmanagement doctor telling
vomiting is compazine or me that my
patient is allergic to
prochlorperazine. parabens.
What happensThe patient
if you havehas been responsive
a patient to Lidoderm,
who has nausea Lidoderm
and vomiting andpatches, but nowan
you administer has
oral
developed an allergic reaction. Can you compound something similar to that? First of all, I said, “Thank
medication to them. A lot of times they can't hold it, they can't tolerate it, so they’ll give it right back to us. A you
doctor. I didn’t know Lidoderm had parabens, so I learned something.” We went back to the data and looked at
the cream basis that had no parabens. I compounded something for that particular patient, so the patient could
tolerate the medicine and get the clinical benefits. What are the service areas? I'll make it easy for you. Virtually,
every field of medicine, starting from podiatry, pain management, physical medicine and rehab, all the way
down to neurologist sports medicine, even dentistry. We'll discuss some of the therapeutic areas and go
well-trained compounding pharmacist can take prochlorperazine, put on transdermal gel or cream base, and
patient would apply it transdermally to the wrist area or behind the ear to get systemic absorption. The reason
you apply it on your wrist or behind the ear, because the tissue concentration is quite thin here, so you get
systemic absorption. In pain management who also do what we call individualized pain management. As I talk
more about transdermal therapeutic approaches, we'll talk about combining various classes of drugs into one
product to help your patients with the compliance and improve efficacy. Dermatology, a very common field in
our practice where we create medications for acne, various fungal infections, psoriasis, for scars, vitiligo,
eczema and warts. We’ll touch some of these as we go through the presentation. Exercise and sports
medicine, a huge part of our practice where a lot of solutions that we offer are transdermal pain creams and
gels that combine nonsteroidal anti-inflammatories with muscle relaxants, various neuropathic agents.
Bioidentical hormones, a very big part of many compounding practices, has gained a lot of momentum over the
well-trained compounding
last several years, pharmacist
especially as Oprah can
and take prochlorperazine,
Dr. Oz putpatients,
bring onto a lot of on transdermal geltake
where we or cream base, and
the same
patient would
biodentical apply it transdermally
hormones that we have in toour
thebodies.
wrist area or diminish
They behind the earage.
with to get
Wesystemic
introduceabsorption. Thepatients
it back to our reason
you apply it on your wrist or behind the ear, because the tissue concentration is quite thin here, so you get
through natural sources with the physicians, making sure those hormones are within normal levels. Quite often,
systemic absorption. In pain management who also do what we call individualized pain management. As I talk
I'm asked, "How do you know how to dose these medications?" Well, first of all, remember as I told you,
more about transdermal therapeutic approaches, we'll talk about combining various classes of drugs into one
everything a well-trained compounding pharmacist does has evidence to support it. We also use something
product to helpscience
called applied your patients with of
in the field the compliance and
compounding. Whatimprove efficacy.
does that mean? Dermatology, a verythat
Well, if we know common
somethingfield in
is
our practice where we create medications for acne, various fungal infections, psoriasis, for scars, vitiligo,
indicated or works for a need, let's say transdermal formulation that works for applications that in need, we can
eczema and warts. We’ll touch some of these as we go through the presentation. Exercise and sports
derive that, it probably works on other joints as well.
medicine, a huge part of our practice where a lot of solutions that we offer are transdermal pain creams and
gels that combine nonsteroidal anti-inflammatories with muscle relaxants, various neuropathic agents.
[10:07]
Bioidentical hormones, a very big part of many compounding practices, has gained a lot of momentum over the
last several
I'll give years,
you an especially
example as Oprah and
of progesterone, Dr.this
and Oz is
bring onto a lotofofapplied
an example patients, wherewe
science weusetake the asame
quite bit in our
biodentical hormones that we have in our bodies. They diminish with age. We introduce it back to our patients
hormone practice. Progesterone is available commercially in 100 milligram capsules and 200 milligram
through natural sources with the physicians, making sure those hormones are within normal levels. Quite often,
capsules. Brand name is Prometrium. Are you guys familiar with that? If you look at the package insert, FDA-
I'm asked, "How do you know how to dose these medications?" Well, first of all, remember as I told you,
approved package insert, it tells you that only 10% of orally administered product is bioavailable. If your patient
everything a well-trained
takes 400 milligrams, compounding
which pharmacist
is the maximum approved does hasdose,
FDA evidence to support
they’re getting 4it.milligrams
We also use something
in the system. If
called applied science in the field of compounding. What does that mean? Well, if we know that
I'm asked as a compounding pharmacist to formulate a progesterone cream for a patient, I'm going to assume something is
indicated or works for a need, let's say transdermal formulation that works for applications that in need, we can
that if I do a transdermal application, 40 milligrams or 4% cream is the maximum we can administer to the
derive that, it probably works on other joints as well.
patient. You talk to well-trained compounding pharmacists when you use the concept of applied science to
explain dosing and other considerations. Dental needs, we work quite a bit with dentists as well, and I'll give
[10:07]
you a few examples. What happens if you have a patient who’s on warfarin, who needs a major dental surgery?
Generally, what happens, an oral surgeon picks up the phone and calls primary care physician and tells them,
I'll give you an example of progesterone, and this is an example of applied science we use quite a bit in our
"I'm going to do a dental surgery, a major surgery in a week or a few days from now. I want the patient to stop
hormone practice. Progesterone is available commercially in 100 milligram capsules and 200 milligram
taking warfarin so they don’t bleed to death.” Of course, there is discussion. Well, what if I tell you that there is
capsules. Brand name is Prometrium. Are you guys familiar with that? If you look at the package insert, FDA-
a substance that I’ve put in solution called tranexamic acid, and there is plenty of data to show that if patients
approved
rinse with package insert,
that solution it tells
before, you that
during andonly
after10% of orally
surgery, you administered product
could have your is on
patient bioavailable. If your
warfarin and patient
go on with
takes 400 milligrams, which is the maximum approved FDA dose, they’re getting 4 milligrams in
the surgery. The data suggest that there are no complications. The solution is compounded by a compoundingthe system. If
I'm asked as a compounding pharmacist to formulate a progesterone cream for a patient, I'm going to assume
pharmacist, tranexamic acid 5%. There is also data to show that if you use tranexamic acid intravenously
that if I do a transdermal application, 40 milligrams or 4% cream is the maximum we can administer to the
during surgery, it’s been used for knee and hip replacements, that there is no bleeding complications. There's
patient. You talk to well-trained compounding pharmacists when you use the concept of applied science to
explain dosing and other considerations. Dental needs, we work quite a bit with dentists as well, and I'll give
you a few examples. What happens if you have a patient who’s on warfarin, who needs a major dental surgery?
Generally, what happens, an oral surgeon picks up the phone and calls primary care physician and tells them,
"I'm going to do a dental surgery, a major surgery in a week or a few days from now. I want the patient to stop
also some studies with tranexamic acid for used topically during surgery, but it's too early to say whether it's
totally safe. Then, there is a physician, a podiatrist, a lower extremity doctor. It's a medical group within one
physician, because you are a surgeon, you are a plastic surgeon, you're a dermatologist, you're a
rheumatologist, you're a neurologist and many other specialties. So, compounding pharmacist offers a number
of solution to the podiatrist for fungal infections, for wound care, diabetic neuropathy, for vascular issues,
warts, calluses, even excessive perspiration. What are the dosage forms that a compounding pharmacist can
formulate? Well, I'll make it very simple again. Every dosage form that's available commercially, a compounding
pharmacist can formulate for you, whether it's oral capsules and liquids. We’ll talk more about transdermal gels.
We could even formulate lollipops for kids, putting medications and flavoring. Flavor them, basically any flavor
the kid wants. We could develop suppositories, enemas, rapid dissolve tablets, nasal and otic preparations. I’ll
give you an example of creative solution. How many of you are familiar with trigeminal neuralgia? A very tough
also sometostudies
condition withbasically
treat, but tranexamiconeacid forpossible
of the used topically during
solutions is insurgery,
lidocainebut it's too
nasal early
spray, to say
a very whether
simple it's
solution
totally safe. Then, there is a physician, a podiatrist, a lower extremity doctor. It's a medical group within one
but quite effective. Where a compounding pharmacist formulates 8% lidocaine spray, patient sprays upon
physician, because you are a surgeon, you are a plastic surgeon, you're a dermatologist, you're a
attack and there is decreased incidents and severity of attacks. I'm sure many of you are familiar with
rheumatologist, you're a neurologist and many other specialties. So, compounding pharmacist offers a number
transdermal drug delivery. We have a number of commercial products that use transdermally and also a
of solution
number to the podiatrist
of compounded for fungal infections,
preparations forpopular,
that are very wound care, diabetic neuropathy,
your transdermal for vascular
drug delivery. They areissues,
effective in
warts,
number of conditions, starting from arthritis to sports injuries, musculoskeletal pain, neuropathies, cancer can
calluses, even excessive perspiration. What are the dosage forms that a compounding pharmacist pain
formulate? Well, I'll make it very simple again. Every dosage form that's available commercially, a compounding
and various physical therapy conditions. Many patients with rheumatoid and osteoarthritis can benefit from
pharmacist can formulate for you, whether it's oral capsules and liquids. We’ll talk more about transdermal gels.
those transdermal formulations. Here is an example of transdermal formulation using a nonsteroidal and
We could even formulate lollipops for kids, putting medications and flavoring. Flavor them, basically any flavor
anesthetic. By working with a compounding pharmacist, you're not limited to a particular nonsteroidal. You
the kidchoose
could wants. aWe could of
number develop
them. suppositories,
You could startenemas, rapid dissolve
with ketoprofen. tablets,
You could go tonasal and oticpiroxicam,
ibuprofen, preparations. I’ll
give you an example of creative solution. How many of you are familiar with trigeminal neuralgia? A very tough
indomethacin.
condition to treat, but basically one of the possible solutions is in lidocaine nasal spray, a very simple solution
but quite effective. Where a compounding pharmacist formulates 8% lidocaine spray, patient sprays upon
[15:03]
attack and there is decreased incidents and severity of attacks. I'm sure many of you are familiar with
transdermal drug delivery.
You have a number We have
of choices. I worka number of commercial
closely with products that
a pain management use transdermally
physician who always andtellsalso a
his residents
number
and otherofphysicians
compounded preparations
he is that“A
teaching said, are very popular,
doctor your transdermal
should know drug delivery.
three nonsteroidals.” They
Why is areWell,
that? effective
if youin
number of conditions, starting from arthritis to sports injuries, musculoskeletal pain, neuropathies, cancer pain
had 100 patients and you put them on the first nonsteroidal, 30 of them will come back to you and say, "Doc, it
and various physical therapy conditions. Many patients with rheumatoid and osteoarthritis can benefit from
does not work." You take the second group of 30 patients, put them on the second nonsteroidal, 30% of that
those transdermal formulations. Here is an example of transdermal formulation using a nonsteroidal and
group will come back to say it does not work. So, you’re left with 10 patients. Third group, you put on third
anesthetic.
nonsteroidalBy working
and with
three of a compounding
them will come back. pharmacist, you're
Those three, younot
sendlimited to amanagement.
to pain particular nonsteroidal. You
With compound,
could choose
they give a number
options. If yourofpatient
them. doesn't
You could start with
response ketoprofen.you
to diclofenac, Youcould
couldswitch
go to ibuprofen, piroxicam,
to indomethacin. You could
indomethacin.
switch to the ketoprofen. We can combine different nonsteroidals to get synergistic effect. Sports injuries is a
huge part of our practice. Guafenesin, how many of you know what that is? It's an expectorant, right? Well, it's
[15:03]
not just an expectorant. At 10% and above transdermally, it becomes a muscle relaxant. We use it quite a bit in
our sports management formulations. The key there is to put a 10% in the transdermal gel base. Neuropathic
You
pain,have a number
a very common ofcondition,
choices. I I'm
work closely
sure all of with a pain
you see management
regularly in your physician who always
clinical practices. Manytells his residents
pathologists
and other physicians he is teaching said, “A doctor should know three nonsteroidals.” Why is that? Well, if you
leading to it, starting from shingles to postherpetic neuralgia, diabetic neuropathy, even vitamin deficiencies. I
had 100 patients and you put them on the first nonsteroidal, 30 of them will come back to you and say, "Doc, it
want to read a definition to you, not to teach you about neuropathic pain but rather to drive a point home.
does not work." You take the second group of 30 patients, put them on the second nonsteroidal, 30% of that
Some neuropathic pain arises as a result of a primary lesion or dysfunction of the nervous system, which leads
group will come back to say it does not work. So, you’re left with 10 patients. Third group, you put on third
nonsteroidal and three of them will come back. Those three, you send to pain management. With compound,
they give options. If your patient doesn't response to diclofenac, you could switch to indomethacin. You could
switch to the ketoprofen. We can combine different nonsteroidals to get synergistic effect. Sports injuries is a
huge part of our practice. Guafenesin, how many of you know what that is? It's an expectorant, right? Well, it's
to the loss of the capacity to conduct information. The nervous system is, in a sense, short circuited and action
potential generation becomes out of control. Essentially, you get abnormal wiring. You have connections,
neurotransmitters and receptors not working properly together. But what's key here is that single
pharmacological approach often is not as effective as multiple approaches. Well, we know that but let me drive
it on further. This is a list of products of chemicals that you now have in your clinical toolbox, whether they are
available commercially, or whether they are not available commercially, and maybe available through a
compounding pharmacist. You have a product, NMD antagonist, glutamate antagonist, tricyclic
antidepressants, GABA agonist. Dextromethorphan, do you guys remember what that is? It's a cough
suppressant. We talked about a guaifenesin, an expectorant, now, we're talking about dextromethorphan. Well,
about cough medicines here, right? Well, dextromethorphan, at 10% and above, if you put on a transdermal
cream or base, that becomes an NMD antagonist, similar to ketamine, similar to methadone. Loperamide, can
to the losstell
someone of me
the what
capacity
thatto
is?conduct information.
Loperamide The nervous
is Imodium, system is,
an antidiarrheal in a sense,
product. Why short circuited
am I talking and about
to you action
potential generation becomes out of control. Essentially, you get abnormal wiring. You have connections,
loperamide, antidiarrheal product in compounding and neuropathic pain? Well, the way loperamide works for
neurotransmitters
diarrhea, it hits theand receptors notinworking
neuroreceptors the gut. properly together.
By hitting But what's key
the neuroreceptors here
in the is itthat
gut, single
slows GI motility. Well,
pharmacological approach
we have new receptors often is not
peripherally as effective
in our skin and as multiple
tissues, so approaches. Well,loperamide
we routinely use we know that butthe
to get let opioid-
me drive
it on further. This is a list of products of chemicals that you now have in your clinical toolbox, whether they are
like effect without giving our patients opioids. That's a clinical option that you have available. If your patient has
available
circulationcommercially, or whether
or vascular issues, they add
we could are not available
nifedipine to commercially,
the formulation. andAllmaybe
of these available
products through
are now a
compounding pharmacist. You have a product, NMD antagonist, glutamate antagonist, tricyclic
available in your clinical toolbox by working with a compounding pharmacist. Where do you apply transdermal
antidepressants,
gels and creams?GABA agonist. Dextromethorphan,
Well, obviously, you could apply todo you guys
where remember
it hurts. You couldwhat
applythattois? It's a cough
original site of injury.
suppressant. We talked about a guaifenesin, an expectorant, now, we're talking about
But what's interesting, and there is data to support it, you could instruct your patients to apply it to adextromethorphan. Well,
about cough medicines here, right? Well, dextromethorphan, at 10% and above, if you put on a transdermal
dermatome. And to practice, very common if you look podiatry, where doctor points out to the caregiver most
cream or right
likely the base,place
that becomes an NMDand
to apply dorsally antagonist, similar
to the site to ketamine,
of pain. Of course,similar to methadone.
you could apply to the Loperamide,
trigger point.can
someone tell me what that is? Loperamide is Imodium, an antidiarrheal product. Why am I talking to you about
How does transdermal drug delivery work? Well, a number of years ago, a new technology was developed,
loperamide,
PLO technology,antidiarrheal
pluronic product in compounding
lecithin organogel. What’sand neuropathic
really cool about pain?
that Well, the waythat
technology, loperamide works
it has a lipid for
phase
diarrhea,
and it hasitahits thesoluble
water neuroreceptors in the
phase. That gut. By technology
particular hitting the neuroreceptors
is able to combinein the gut,
lipid it slows
soluble GI motility.
drugs and waterWell,
we have new receptors peripherally in our skin and tissues, so we routinely use loperamide to get the opioid-
soluble drugs in one cream or gel.
like effect without giving our patients opioids. That's a clinical option that you have available. If your patient has
circulation
[20:03] or vascular issues, we could add nifedipine to the formulation. All of these products are now
available in your clinical toolbox by working with a compounding pharmacist. Where do you apply transdermal
gels
That'sand
howcreams? Well,toobviously,
we're able you medications
deliver those could apply to where ittohurts.
together You could
the patient. What apply to original
are the site ofofinjury.
advantages the
But what's interesting, and there is data to support it, you could instruct your patients to apply it to a
transdermal drug delivery? Well, we avoid systemic side effects. Most of the transdermal drugs that are
dermatome. And to
delivered achieve practice,
high tissue very common if but
concentrations youvery
looklow
podiatry, where
systemic doctor
levels. points
It will outliver
bypass to the caregiver
and kidneys.mostIt
likely the right place to apply dorsally and to the site of pain. Of course, you could apply to the trigger point.
generally have no GI irritation. It is cost affective. As I mentioned before, you get low plasma concentrations for
How
most does
drugs,transdermal drug
not for all but fordelivery
most. Thework? Well, a number
disadvantages are of years
very ago,
minor. Inamynew technology
practice, was developed,
on occasion, I hear a
PLO technology, pluronic lecithin organogel. What’s really cool about that technology, that it has
possible skin irritation. Most likely, it's a reaction to the inactive drug or inactive filler or cream base. These a lipid phaseare
and it has a water soluble phase. That particular technology is able to combine lipid soluble drugs and water
some sample neuropathic pain formulations that are requested frequently in our practice. For example, the first
soluble drugs inamitriptyline
one combines one cream and or gel.
tricylic antidepressant, gabapentin, ketoprofen and lidocaine and a transdermal
cream base. It's important to let your patients know to apply it for up to 10 days to reach high tissue
[20:03]
concentrations. If after 10 days your patients come back to you and says, "Well doc, it doesn't work as well as I
wanted to.” We could adjust this formula to anything you want. If you look at the second formulation, we
That's how we're able to deliver those medications together to the patient. What are the advantages of the
transdermal drug delivery? Well, we avoid systemic side effects. Most of the transdermal drugs that are
delivered achieve high tissue concentrations but very low systemic levels. It will bypass liver and kidneys. It
generally have no GI irritation. It is cost affective. As I mentioned before, you get low plasma concentrations for
most drugs, not for all but for most. The disadvantages are very minor. In my practice, on occasion, I hear a
increase gabapentin to 10%, add some ketamine, keep the ketoprofen and lidocaine. That's a step up from the
first formula. Let's say after 10 days of therapy or a month of therapy, your patient is requesting some
additional support. You have an option to bump it up to even more complex formulation. The possibilities are
endless here. This is an example of some formulas that are commonly requested in our practice for arthritic
patients. Very simple formulas, some of them combine a couple of nonsteroidals. The idea is to get synergy,
which with the two products. Also, give you clinical options. If your patient doesn’t respond to indomethacin,
you could put them on diclofenac or ketoprofen or even Celebrex, or Celecoxib transdermally. Wound care and
skin infections is an important part of many podiatrist practices. I'll introduce a couple of agents to you that you
may or may not be familiar with. Phenytoin is an old anti-epileptic drug. One thing we know that patients who
are taking phenytoin, they have to go quite often to the dentist to trim their gums, because phenytoin causes
something called gingival hyperplasia. From that, we learn that it promotes granulation. It also inhibits formation
increase gabapentin
of collagenase, to 10%, add
and therefore some collagen
increases ketamine,synthesis.
keep the Misoprostol
ketoprofen and
is a lidocaine.
product weThat's a step up from
see commercially in the
first formula.
Arthrotec, Let'scombined
which say after with
10 days of therapy
diclofenac, is aor a month
PGE1 of therapy,
analogue your your
that helps patient is requesting
mucosal stomach some
lining. If it
additional support. You have an option to bump it up to even more complex formulation. The possibilities are
helps regenerate mucosal stomach lining, it helps regenerate tissues and wound care as well. Hyperhydrosis, a
endless here. This is an example of some formulas that are commonly requested in our practice for arthritic
common condition I'm sure many of you see regularly in your practices, with limited commercial options. Now,
patients. Very simple formulas, some of them combine a couple of nonsteroidals. The idea is to get synergy,
we have a few other options. We could do glycol paraloid deodorant. We could increase the aluminum
which with the two
concentrations products.
in your Also,
patient's give you clinical
deodorants to 20%.options.
We couldIf your patient doesn’t
do formaldehyde respond
solution, to indomethacin,
a number of clinical
you could put them on diclofenac or ketoprofen or even Celebrex, or Celecoxib transdermally.
options. Plantar warts, a difficult to treat condition, sometimes frustrating for many doctors. But once again, Wound care and we
skin infections is an important part of many podiatrist practices. I'll introduce a couple of agents to you that you
have a number additional options here that you could use in your clinical toolboxes. The first formulation on the
may or may not be familiar with. Phenytoin is an old anti-epileptic drug. One thing we know that patients who
slide is a combination of cream product that a patient applies at home for about four to eight weeks. The
are taking phenytoin, they have to go quite often to the dentist to trim their gums, because phenytoin causes
second product is a combination of cantharidin, podophyllin and salicylic acid. It's a combination of
something called[23:58]
[indecipherable] gingival hyperplasia.
agents, where itFrom
mustthat, we learn that in
be administered it promotes granulation.
a physician's office under It also inhibits formation
doctor's
of collagenase,
supervision. and therefore increases
Onychomycosis, collagen
a very common synthesis.
condition withMisoprostol is a product
limited commercial we see
options. commercially
I know it's a in
Arthrotec, which combined with diclofenac, is a PGE1 analogue that helps your mucosal stomach lining. If it
frustrating condition to treat sometimes for many podiatrists. Here, I'm listing a few other options that exist
helps regenerate mucosal stomach lining, it helps regenerate tissues and wound care as well. Hyperhydrosis, a
through compounding pharmacist. Dermatitis, we heard a very nice lecture earlier about dermatitis. Generally,
common condition I'm sure many of you see regularly in your practices, with limited commercial options. Now,
the mainstay of therapy is corticosteroids. What if you don't want to go with corticosteroids? Well, you have a
we haveother
couple a fewoptions
other options. We could
here. Cromolyn do glycol
sodium is anparaloid deodorant.
old asthma medicine,Wenotcould increase
available the US
in the aluminum
commercially,
concentrations in your patient's deodorants to 20%. We could do formaldehyde solution,
but you can get it through a compounding pharmacist. It's a mast cell stabilizer and decreases pruritus a number of clinical
options. Plantar warts, a difficult to treat condition, sometimes frustrating for many doctors. But once again, we
intensity, erythema and severity. You also have an option with tranilast, which is also a mast cell stabilizer, but it
have a number additional options here that you could use in your clinical toolboxes. The first formulation on the
also inhibits collagen synthesis, which makes it a very useful product in dermatitis but also in scar therapy.
slide is a combination of cream product that a patient applies at home for about four to eight weeks. The
second
[25:05] product is a combination of cantharidin, podophyllin and salicylic acid. It's a combination of
[indecipherable] [23:58] agents, where it must be administered in a physician's office under doctor's
supervision. Onychomycosis, a very common condition with limited commercial options. I know it's a
I know we are tight on time here, so I'm going to zoom some of these slides. These are some of the examples
frustrating condition to treat sometimes for many podiatrists. Here, I'm listing a few other options that exist it
of the scar formulations that are prescribed commonly by physicians we work with. Tamoxifen, you could see
through compounding pharmacist. Dermatitis, we heard a very nice lecture earlier about dermatitis. Generally,
in the second formulation. Do you guys remember what that is? It's an antiestrogen product used by breast
the mainstay
cancer of therapy
survivors. Well, atis0.1%,
corticosteroids.
tamoxifen What if you
inhibits don'tsynthesis,
collagen want to gomaking
with corticosteroids?
it a very useful Well, youinhave
product scara
couple
therapy.other options
The key here.
in the scarCromolyn sodium
formulation is an the
is to have old right
asthma medicine,
base that younot available
deliver in the US
your drugs commercially,
in and most often,
but you can get it through a compounding pharmacist. It's a mast cell stabilizer and decreases pruritus
we deliver that in a silicon-based gel. Picture is worth a thousand words as they say, so this is an example of a
intensity, erythema and severity. You also have an option with tranilast, which is also a mast cell stabilizer, but it
scar formulation used for an ankle scar and you could see the results that are pretty dramatic I think, day one
also inhibits collagen synthesis, which makes it a very useful product in dermatitis but also in scar therapy.
[25:05]
I know we are tight on time here, so I'm going to zoom some of these slides. These are some of the examples
and day 14. This is an example of a child who's got a facial burn and you could see the results there day one
and day eight of a scar formulation using a silicon-based gel. Plantar fasciitis, condition seen by many of you
but now we have more option and many more options actually. This is just an example of one more option. This
is a formula requested often from our compounding pharmacy by podiatrists. It combines a nonsteroidal
baclofen verapamil and bupivacaine, very useful and therapeutically efficacious formulation. I talked to you
about a lot of concepts but this concept is only as effective as the working clinical practice. We are fortunate to
have a good collaborative relationship with Dr. Akhtar who is a friend and a colleague and Dr. Akhtar is going to
share with you a few of the clinical studies, clinical case studies from his practice.
Dr. Akhtar: Hello everyone. Yeah, with all of the formulations that Emil has talked about is a lot of medications
that I've actually prescribed and used with a great deal of success. I've been using compound medications now
and day 14.
for about fiveThis is an
to six example
years of a child
and partly becausewho'sit'sgot a facial
a form burn and
of therapy thatyou could
other see the results
practitioners there day
necessarily one
offer but
and day eight of a scar formulation using a silicon-based gel. Plantar fasciitis, condition seen by many of you
primarily because of the results. First, I will just give you two brief examples of patients. One is a retired peace
but now we have more option and many more options actually. This is just an example of one more option. This
officer who with diabetes and the obvious onset of neuropathy had severe symptoms, moderate to severe
is a formulaofrequested
symptoms often
your classic from our compounding
neuropathic burning, pain,pharmacy by all
tingling and podiatrists. It combines
of the above. a nonsteroidal
Initially, everything was
baclofen verapamil and bupivacaine, very useful and therapeutically efficacious formulation.
effectively I treated for a number of years with Metanx and Lyrica. But as the years progressed, unfortunately, I talked to you
about a lot of concepts
he developed but thisand
prostate cancer concept
was thenis only as effective
initially started, as the working
obviously clinical
started practice. We are
on chemotherapy. So,fortunate
he cametoin
have a good collaborative relationship with Dr. Akhtar who is a friend and a colleague and Dr. Akhtar is going to
to the office multiple times complaining of just exaggerated pain and we increased the dosage of various oral
share with you a few of the clinical studies, clinical case studies from his practice.
medications and I was left with no choice but to give him some opioids. Even with that, obviously we couldn’t
maintain him long term. As a result, I gave him a formulation. This formulation is the one that you see over here.
Dr. Akhtar:
Without theHello everyone.
medication, theYeah, with
patient all of the
is having formulations
severe thatsymptoms.
significant Emil has talked about
With the is a lot of he
medication, medications
is
that
essentially pain free. Another case that I have is a male that's initially presented to a vascular surgeon over anow
I've actually prescribed and used with a great deal of success. I've been using compound medications
for about five to six years and partly because it's a form of therapy that other practitioners necessarily offer but
decade ago. He's still in his 40s. He was basically treated for venous stasis ulcerations. When the failed
primarily because of the results. First, I will just give you two brief examples of patients. One is a retired peace
treatment consisting of all the above coming from just conservative management, topical treatments,
officer who with
compressor diabetes
dressings, and themultiple
multiple, obviousvascular
onset ofinterventions,
neuropathy had severe
after symptoms, moderate
graft applications, the works, to with
severe
symptoms of yourDo
everything failing. classic neuropathic
we have any slidesburning, pain, tingling and all of the above. Initially, everything was
of the --
effectively I treated for a number of years with Metanx and Lyrica. But as the years progressed, unfortunately,
he
Dr. developed prostate
Emil Haldey: Yes, wecancer
have aand was then initially started, obviously started on chemotherapy. So, he came in
slide.
to the office multiple times complaining of just exaggerated pain and we increased the dosage of various oral
medications and Iactually
Dr. Akhtar: Okay, was leftthis
withpicture
no choice but to
we have give
over himissome
here opioids.
actually Even
an after withofthat,
effect whatobviously we couldn’t
I use in terms of a
maintain
particular formulation and that formulation being this. That, again going back to a previous picture. This here.
him long term. As a result, I gave him a formulation. This formulation is the one that you see over
Without
previousthe medication,
picture thelarge
here. This patient is having severe
geographical area issignificant symptoms.
an area that With the
was essentially medication,
open he years.
for multiple is He
essentially pain free. Another case that I have is a male that's initially presented to a vascular surgeon over a
would call me at odd hours at night and we’re talking about two or three in the morning, stating he's got
decade ago. He's still in his 40s. He was basically treated for venous stasis ulcerations. When the failed
profuse bleeding and the area is extremely painful.
treatment consisting of all the above coming from just conservative management, topical treatments,
compressor
[30:04] dressings, multiple, multiple vascular interventions, after graft applications, the works, with
everything failing. Do we have any slides of the --
And as a result again, we have to do, we did it at that time, we just constantly applying compressor dressings
Dr. Emil Haldey: Yes, we have a slide.
and hope for the best. Intervention with the dermatologist prove to be truthful either but after doing maybe a
fifth soft tissue biopsy and essentially came back as a necrobiosis lipoidica. So what do we do different? Well,
Dr. Akhtar: Okay, actually this picture we have over here is actually an after effect of what I use in terms of a
particular formulation and that formulation being this. That, again going back to a previous picture. This
previous picture here. This large geographical area is an area that was essentially open for multiple years. He
would call me at odd hours at night and we’re talking about two or three in the morning, stating he's got
profuse bleeding and the area is extremely painful.
nothing major, other than the fact that I went to that’s a formulation and as a result, what you see there is not
brilliant but highly, highly effective in terms of him going for a swim, and having a bath, having a shower and for
the last two years, he hasn't has had any constant or consistent episodes of cellulitis.
Dr. Emil Hadley: Thank you Dr. Akhtar. Also as we discussed the patient earlier, you had a patient on oral Trental
pentoxifylline. Was it this particular patient? This particular patient was also treated with oral pentoxifylline,
Trental and another option that’s available to doctors is to deliver pentoxifylline transdermally. You can redeliver
it together with the rest of the wound care products. Once again, more clinical options available for you and
your toolboxes. So to conclude, to me, a podiatrist is a physician that sees it all and does it all. You are a
multispecialty physician group in one doctor. You are the dermatologist, the neurologist, the rheumatologist, the
plastic surgeon, the regular surgeon, you do it all. And you have a lot of conditions that you treat and by
nothing
partneringmajor,
withother than the fact
a compounding that I wentyou
pharmacist, to that’s
have amany
formulation and astools
more clinical a result, whatto
available you see
you forthere is not
various
brilliant
conditionsbutstarting
highly, highly effective
from pain, in terms
and fungal of him going
infections, for a swim,
to wound and having warts
care, dermatitis, a bath, having
and a shower and for
calluses,
the last two years,
hyperhydrosis and he hasn't
many has
other had any constant
conditions. I shared or consistent
a lot episodes
of concepts of cellulitis.
with you. These concepts are only as good
as concepts and they say knowledge is not power, it's only potential power that becomes real through use. So I
Dr. Emil Hadley: Thank you Dr. Akhtar. Also as we discussed the patient earlier, you had a patient on oral Trental
challenge you all to ask us questions. I also know that I presented a lot of concepts and formulas. I want to
pentoxifylline.
welcome you to Was it this
speak to particular
me through patient? Thisnow
questions particular
but alsopatient
we'll was also treated
be around with oral
throughout the pentoxifylline,
conference. You
Trental and another option that’s available to doctors is to deliver pentoxifylline transdermally.
could find us at our booth, we have special materials presented to be shared with you where we Youcapture
can redeliver
all of
it together
these with the
concepts andrest of the and
formulas wound
we care products.
can share Onceyou
that with again, more clinical
physically. optionsI challenge
Once again, available for
youyou and
to work
your toolboxes. So to conclude, to me, a podiatrist is a physician that sees it all and does it all. You are a
with your compounding pharmacist, put those clinical tools to use to help your patients. Thank you.
multispecialty physician group in one doctor. You are the dermatologist, the neurologist, the rheumatologist, the
plastic surgeon, the regular surgeon, you do it all. And you have a lot of conditions that you treat and by
[Applause].
partnering with a compounding pharmacist, you have many more clinical tools available to you for various
conditions starting
Dr. Emil Hadley: Arefrom pain,
there any and fungal or
questions infections,
comments?to wound
Thankcare, dermatitis, warts and calluses,
you all.
hyperhydrosis and many other conditions. I shared a lot of concepts with you. These concepts are only as good
as concepts and they say knowledge is not power, it's only potential power that becomes real through use. So I
challenge you all to ask us questions. I also know that I presented a lot of concepts and formulas. I want to
welcome you to speak to me through questions now but also we'll be around throughout the conference. You
could find us at our booth, we have special materials presented to be shared with you where we capture all of
these concepts and formulas and we can share that with you physically. Once again, I challenge you to work
with your compounding pharmacist, put those clinical tools to use to help your patients. Thank you.
[Applause].
Dr. Emil Hadley: Are there any questions or comments? Thank you all.

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PRESENT Podiatry Online CME & Conferences | Custom Therapy Options in the Modern Podiatry Practice 8/26/18, 9)50 PM

Residency Education / General Medicine

Custom Therapy Options in the Modern Podiatry Practice

Start your Pre-Test to begin the CME progress for credits.

Requires: Pre-Test, View Lecture

Requires: Pre-Test, View Lecture, PostTest

Requires: All Content Above

Complete the 4 steps to earn your CE/CME credit:

1. Complete the Pre-Test

2. View the Lecture

3. Complete the Quiz (Min. 70% Passing Score)

4. Complete the program Survey

Goals and Objectives

Complete the 4 steps to earn your CE/CME credit:

2. Highlight the conditions in which custom therapies can be utilized

5. Discuss clinical case studies

Accreditation and Designation of Credits

2. Highlight the conditions in which custom therapies can be utilized

This lecture has

Teaching Hospitals Residency Education Review Committee.

Emil Haldey, PharmD

To view Lectures online, the following specs are required:

256MB minimum of RAM

Adobe Acrobat Reader (Free) to print certificates

Firefox class or better processor

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