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Podiatry Management Online


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12/17/2012    Allen Jacobs, DPM

Efficacy of "Pain" Creams (Tip Sullivan, DPM)

I have utilized compounded medications
increasingly over the past 3-4 years, including
those from Total Pain Solutions, Trilogy, and
Bellevue Pharmacy for whom I am a consultant and
do clinical research.

Compounding offers many advantages to patient
care. In the case of topical pain management, I
am able to prescribe anti-inflammatories for the
patient in whom the use of an anti-inflammatory
might otherwise be either contra-indicated or of
concern, such as the patient with CHF,
hypertension, renal dysfuction, or GI concerns,
since these medications are typically associated
with plasma levels 1% or less of the same
medications administered orally. This is
particularly helpful for the patient requiring
chronic use, such as the patient with Achilles
tendinosis, plantar fasciitis, hallux limitus.

Additionally, the topical application of an anti-
inflammatory is associated with up to 100X
increased concentration of the medication at the
site of pathology, when compared to the same
medication administered orally. Topically
applied medications will penetrate to muscle and
synovial fluid in clinically effective

With regard to symptomatic neuropathy with
parasthesia and/or dysesthesia, I frequently
combine topical management with remittive agents
such as Metanx or alpha lipoic acid. The use of
agents topically such as gabapentin, ketamine,
clonidine, imiprimine, allows me to treat
patients with anti-depressants, anti-
convulsants, or analgesics, without the worry of
neuropsychiatric, anti-cholinergic, or other
very concerning side-effects and sequellae.

In the case of wound care, compounding allows me
to treat the patient without have to "select a
product". For example, I can compound a
debridement agent with for example, phenytoin to
increase fibroblast production, with say
nifedipine to increase vascular perfusion, with
say,metronidazole or other antibiotics. I can
look at a wound, determine what the needs are,
and achive multiple effects at one time.

In addition, I can combine analgesics such as
lidocaine, tetracaine, bupivacaine to offer pain
relief for the painful ulcer, for neuropathy
pain, for arthritic pain, and so on.

For common dermatologic disorders, compounding
may be utilized to increase effective
management. For example, I can combine topical
anti-fungals with tea tree oil, keratolytics,
emollients, or add ibuprofen (which has a
synergystic effect with azole ant-fungals) for
treatment of tinea pedis or onychomycosis.

The safety and efficacy of topical compounded
medications are well established and literature
on the subject available to anyone wishing to be
informed on the subject.

Finally, the use of compounding offers the
podiatric physicians to use medications in
combinations and strengths determined to be
appropriate for each patient, rather than be
restricted to the components of premade standard

Disclosure: I lecture for and research for
Bellevue pharmacy, a compounding company.

Allen Jacobs, DPM, St. Louis, MO,

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