Sue Johnson’s 9-year-old autistic son refuses take medicine that smells or tastes nasty. He cannot take pills or capsules either.
The San Clemente, Calif., mom used to hold him down and wrap her legs around him or roll him up in a rug to give him his medications.
These days, Johnson, 36, hands him two gummy half-inch squares that he promptly gobbles: The purple one is grape-flavored Prozac, and the pink square is tutti-frutti-flavored Riserdal for treating hyperactivity.
These are compounded medicines, medications custom-made in the pharmacy. Compounding was the foundation of pharmacy practice for decades before drug mass manufacturers rendered it nearly obsolete in the 1960s and ’70s.
But compounding is enjoying a renaissance because some patients are finding that tailor-made medicine works best for them, said Dennis Saadeh, pharmacist at Park Pharmacy in Irvine, Calif. In the five years since he first offered compounding, Saadeh has seen the number of compounded prescriptions at his pharmacy rise from 5 a day to 45 a day.
Technological advances have enabled him and other pharmacists to work with doctors to come up with the most effective way to deliver medicine to the appropriate parts of the body. Among the most popular compounded formulations are transdermal gels and creams, fast-acting medicines in a gel or ointment applied to the skin. For children, medicine can be made in lollipops and gummy candies with every conceivable flavor.
In many cases, compounding is inadvertently strengthening the old-fashioned notion of a patient, doctor and pharmacist relationship, said Mark Gonzalez, who opened Med Specialties, a compounding-only pharmacy in Yorba Linda, Calif., last year. The three have to constantly communicate and give one another feedback to make sure the medicine is effective.
Among the three parties, the patient is the strongest driving force of compounding’s growing popularity, said Shelly Capps, executive director of the International Academy of Compounding Pharmacists, or IACP.
“Patients are realizing that `one size fits all’ is not always applicable when it comes to medications,” Capps said.
To hear patients tell it, compounding makes a tremendous difference in their lives.
Compounding took the ordeal out of taking medicine for the Johnsons of San Clemente. “Before, the medicine routine would be this cloud over our day,” Sue Johnson said. “It would make [my son] cry and be miserable. He was so angry and frustrated.
“Now, it’s not a big deal.”
Marlene Greby of Laguna Hills, Calif., didn’t like the side effects of the commercial hormone replacement therapy that she had been taking for more than five years. She had headaches and gained weight.
Greby, 61, talked to her doctor about bioidentical hormone replacement therapy, which is made of hormones from humans. “I feel strongly about taking something natural whenever possible,” Greby said.
She said she no longer experiences side effects.
More than half of all prescriptions that Dr. Leigh-Erin Connealy writes are for compounded medications. Connealy is a family medicine practitioner in Tustin, Calif.
“Compounded medicine is like a tailor-made dress or suit,” she said. “A man who is 6-3 tall is going to need something different than a 5-11-tall man even though both wear a size 44 coat.”
Compounding can simplify some medications, Connealy said. “Mass-produced medicine sometimes comes with chemical colorings. In compounding, you can leave all that out of it.”
Other doctors use compounded medicine on their patients during visits before prescribing. Dr. Jay Goldstein, a fibromyalgia specialist in Orange, Calif., has an array of about 200 compounded medications in his clinic. “The usual manner of medical practice is for the doctor to say to the patient, `Take this pill and see me in two weeks.’ Well, some of my patients have come from other countries or states and don’t have the luxury of time.”
Goldstein applies lidocaine in a transdermal gel on the patient’s skin and waits to find out the effect. “If the patient doesn’t like it, you can just wash it off and select the next medication to try,” he said. “It allows me to screen rapidly acting medications in a short time.”
Goldstein says he spends a lot of time discussing with pharmacists the options for each medication, including potency, possible adverse effects, the medium to be used and dosage.
But compounding has a number of limitations.
It is not always covered by insurance. In some cases, compounded medicine can cost more than mass-manufactured medicine.
And not all compounding pharmacies are alike, Goldstein said.
“Some of them are careless in what they do or they don’t provide the patients with good service,” he said.
“Some pharmacists will add flavored syrup to make a [commercially available] medicine taste nicer,” Gonzalez said. “But that’s not compounding. And doing this may alter the effectiveness of the medication.”
Compounding involves controlled experimentation, so pharmacists can make errors or miscalculations or may find later that certain formulations and ingredients may cause adverse effects. These effects are reported to the state board of pharmacy. The board evaluates compounding practice according to the “Good Compounding Practices” formulated by the National Association of Boards of Pharmacy.
Another form of self-regulation comes from the IACP. Early this year, the compounding pharmacists’ academy created a form to regulate and track adverse drug effects of compounded medications prepared by its members. These forms are submitted to the IACP adverse drugs committee for action.
