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2011 Student Essay #1
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Intervention on Quality of Life

Seijo Chow
Loma Linda University
School of Pharmacy
Loma Linda, Calif.

Many lives were lost this year due to the terrifying earthquake followed by the tsunami in Japan. As countless people were directly affected by the incidents, many more are currently affected by the explosion of the nuclear plants. The need for potassium iodide among those in Japan and in the nearby countries as a measure of precaution against the radiation became a huge issue when the demand surpassed the supply. While the tragedy took place during my rotation at an independent compounding pharmacy, I was bombarded with patients requesting the medication since potassium iodide is not commercially available. If people from a country thousands of miles away from Japan are requesting this medication, I could not imagine how cumbersome it must have been for the people in Japan to obtain it for themselves and for their family members. This was when I began to realize that compounding pharmacists play an extremely important role in affecting lives, not just those in the U.S., but also around the world. As I had grown up in Japan, my compounding pharmacist was concerned about the health of my friends, and has kindly offered to ship as much potassium iodide as I needed for my friends and their family. Compounding preventative medications like this is only a miniscule part of what compounding pharmacists do; in a bigger picture, they help to increase the quality of life of many patients who suffer from various diseases that have not gotten the proper treatment using the manufactured medications. Ocular disorders like severe dry eye syndrome and neurotrophic keratitis (inflammation or decreased corneal sensation of the cornea), and nausea due to various conditions are two examples of how compounding pharmacists may affect the current and future healthcare delivery system, and to improve the patients’ quality of life.

There are many people who suffer from dry eyes or neurotrophic keratitis, which may lead to poor vision, ocular irritations, itchiness, burning sensation, eye strain/fatigue, photophobia, a foreign body sensation, and/or sharp stabbing pain. Whether it is due to LASIK treatment, cataract surgery, microvascular disease from diabetes mellitus, etc., ocular discomforts can be so severe that they can affect his/her ability to perform activities of daily living (reading, driving, watching television, etc.). Autologous eye drops, the use of one’s own blood sample to compound an individualized plasma eye drops, have alleviated if not cured many of the signs and symptoms of ocular disorders. In an article called, “Autologous Eye Drops for the Treatment of Dry Eye and Neurotrophic Keratitis,” it talks about a patient who had corneal surface ulcerations in both eyes post cataract surgery. Not only did she have inflammation and dryness in her eyes, but she also had vision impairment so severe that she was at the level of counting fingers (20/100).  When no commercial medications relieved her symptoms, after applying the autologous eye drops for just 3 weeks, she noticed her ocular surfaces were less inflamed and her vision improved tremendously to 20/40 (visual acuity at the ability to drive). Within 3 months of continued use, she became close to being symptom free with a vision of 20/25, which undoubtedly increased her quality of life. In another patient, a 66-year-old male patient who had type 2 diabetes mellitus with hypertension and arthritis experienced bilateral ocular pain of 9 on a pain scale of 1 to 10 on top of decreased visual acuity of 20/20 to 20/400 due to his neurotrophic keratitis. Only 2 months of autologous eye drops use improved his eye sight back to 20/20 with no signs of neurotrophic keratitis. When some of the dry eye syndromes cannot be relieved by the commercial medications such as Restasis and more complicated ocular diseases are not relieved by topical antibiotics and steroid eye drops, autologous eye drops can be the single treatment for patients whose daily activities are hindered by the continuous eye discomforts. Since plasma eye drops mimic the patient’s own tears, they have nonallegenic properties with fibronectin, growth factors, and vitamins that support the migration, proliferation, and differentiation of the conjunctival and corneal epithelium. They also work to help to exert mechanical, optical, antimicrobial, and nourishing ocular effects essential for good visual acuity.1 Compounding medications such as autologous eye drops are only one way a compounding pharmacist can improve the patients’ quality of life; they can also help patients relieve symptoms such as nausea in various ways.
Patients who are undergoing chemotherapy or radiation therapy for cancer treatment, experiencing GI upset due to flu, or various other factors frequently cause nausea and vomiting.

Many antiemetic medications such as ondansetron and metoclopramide are in the form of oral tablets, suspensions, and intravenous, and those whose nausea is moderate to severe would take either oral disintegrating tablets or receive it intravenously. Patients with nausea so severe that they are unable to keep anything down or get to the hospital, a compounding pharmacist can help to create different formulations such as transdermal patches, topical gels/creams, and suppositories. While rotating at the independent compounding pharmacy, one of the employees suffered from extreme nausea/vomiting from contracting flu virus that she could not even get up to go to the emergency room. As soon as she notified her absence, the pharmacist obtained a prescription and compounded a hydrogel ondansetron transdermal patch for her to apply on her body. After the recovery from the flu, she explained that her nausea subsided within 30 minutes of applying the patch and no longer had the urge to vomit. Although there is research still needed on discovering the optimal formulations for the permeability of antiemetics through the skin, there have been some studies that has shown permeability using the hydrogel. In one study, the feasibility of transdermal delivery system of ondansetron was positively evaluated by determining the molecular weight (293.4) and the apparent partition coefficient (log K = 1.87) of ondansetron.3

The study compared the effectiveness of the hydrogel-based ondansetron vs. placebo on cisplantin-induced reduction of food intake in mice, where the reduction in food intake served as an index of nausea. The results favored the treatment with the ondansetron gel; control group showed a food intake reduction rate of 85.4% and the active group showed a reduction rate of 65.8%. This indicates that the ondansetron released from the optimized hydrogel performed a systemic action via the skin. Not only can the different compounded formulations benefit the adults, but they can also eliminate the difficulty of administering medications among pediatrics. When the commercially available formulations are not an option for the child whether it is unable/unwilling to take the medication orally or intravenously, and/or have difficulty keeping the compounded cream on the skin, suppositories may be the perfect solution with its ease of application and the quick onset of action. As one can see, within one topic of disease management, there are already numerous ways in which a compounding pharmacist can intervene with the patient’s quality of life.

Pharmacists are more than just a healthcare professional who dispense medications or monitor the patients’ medication therapies. Compounding pharmacists have the power to meet the needs of patients who require special treatments through preparing medications not commercially available such as potassium iodide, autologous eye drops, and various formulations of antiemetics. In many other cases, physicians and the patients seek help from compounding pharmacists when certain medications are discontinued, back-ordered, or simply require modification of the dosages or ingredients. Only these types of unique pharmacists are able to meet these requests and any other possible disease management requiring individualized medication therapy. With the optimal medications available for patients, optimal results can be seen, which may also decrease unnecessary side effects or may even treat their conditions with potential placebo effects when they realize they are receiving the best possible treatment.

Although the number of retail pharmacies continues to increase, it is inevitable that they may be replaced by robots decades from now with the technology advancing so quickly. Compounding pharmacists, however, will always be essential for specific needs that cannot easily be met by the “cure-all” machines. All pharmacies were once compounding pharmacies, where the pharmacists were able to take the time to give the best care to the individual patients. It is, therefore, crucial to address and to increase the social awareness of the necessity of compounding pharmacists, both currently and for the future of the pharmacy profession, as they deliver healthcare in a way that significantly improves patients’ quality of life. 

References

1. Mixon, William; Patricea Angelle; and Richard I. Chang. “Autologous Eye Drops for the Treatment of Dry Eye and Neurotrophic Keratitis.” International Journal of Pharmaceutical Compounding, Nov. 2009. Web. 20 Apr. 2011.
2. D. Geerling; G. Hartwig; and S. MacLennan. “Autologous Serum Eye Drops for Ocular Surface Disorders.” University of Lubeck, 11 June 2004. Web. 21 Apr. 2011.
3. Obata, Yasuko; Yuriko Ashitaka; Koichi Isowa; and Kozo Tokayama. “A Statistical Approach to the Development of a Transdermal Delivery System for Ondansetron.” International Journal of Pharmaceutics. Elsevier, 10 Aug. 2010. Web. 22 Apr. 2011.

 

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