Managing Pain in a Non-Traditional Way

Guest post written by Howard Biel, RPh. Howard serves as a Compounding Pharmacist and Pharmacist-In-Charge over Solaris Pharmacy.

Hospice patients often require many different forms of therapy to control pain. Controlling that pain while the patient is undergoing significant changes in his or her disease state is often a challenge for the hospice team.

Nonsteroidal anti-inflammatory drugs (NSAIDs) have long been recognized as a first-line drug of choice in the treatment of osteopathologic pain, which is a symptom that afflicts many hospice patients. NSAIDs are often used to treat other types of pain symptoms (muscle ache, arthritis) as well.

But, oral NSAIDs have a long list of side effects. Not only can they cause stomach ulcers and bleeding by damaging the gastrointestinal mucosa, but there are heart risks, too.  Additionally, selection of effective treatment for patients unable to take oral medication can challenge the hospice team.

So what are the options?  Over the past two decades, good clinical evidence has emerged to demonstrate that topical versions of NSAIDs are well absorbed through the skin and reach therapeutic levels in synovial fluid; muscle, and fascia. With topical use, little drug actually circulates in the plasma, leading to levels that are a fraction of comparable oral doses. As adverse events from NSAIDs are largely dose-related, serious side effects can be minimized.  There are several single-entity topical NSAIDs which have been approved by the Food and Drug Administration for use in the United States.

Two specific NSAIDs have special appeal in our palliative care practice, those being Ketoprofen and Piroxicam.  Ketoprofen has a rapid onset (within 1-2 hours after oral administration) but short duration (four to six hours), while Piroxicam has a slow onset (within 4 hours) but a long duration (up to 24 hours).  Therefore, a topical preparation can combine the two agents to get a quick onset and long duration.  From our hospice patient experience, a transdermal dosage form of Ketoprofen 10% and Piroxicam 2% applied to affected areas twice daily has provided relief to many patients who have been unable to take oral NSAIDs or who have not responded to other transdermal NSAID agents.  The preparation described is not commercially available, but can be compounded by a specially trained and equipped pharmacist.

In the hospice setting, it is important to remember that the best therapy may be one for which the traditional dosing is ineffective.  A compounding pharmacist in palliative care can play a crucial role in designing appropriate non-traditional dosages for hospice patients and in improving the outcome of treatment.