Rectal Propranolol Controls Paroxysmal Sympathetic Hyperactivity Post Brain Injury

Paroxysmal sympathetic hyperactivity (PSH) affects approximately 10% of survivors of acquired brain injury and is associated with substantial morbidity. The most effective maintenance therapies include oral β-blockers and α-2 antagonists. May et al. of the University of Kentucky HealthCare reported the use of rectal propranolol for symptomatic control of PSH in a critically ill patient with an altered gastrointestinal tract for whom oral intake was contraindicated. This is the first case report to describe successful use of propranolol suppositories in a clinical environment. This case supports the use of propranolol suppositories as a potential alternative route when oral administration is not possible.

Pharmacotherapy. 2015 Apr;35(4):e27-31.
Rectal propranolol controls paroxysmal sympathetic hyperactivity: a case report.
Click here to access the PubMed abstract of this article.

Propranolol Suspension

Propranolol hydrochloride is a beta blocker used to treat high blood pressure, abnormal heart rhythms, heart disease, pheochromocytoma, and certain types of tremors. Propranolol is a drug of choice for many diseases such as infantile hemangioma occurring in neonates and infants, an age group for which oral suspensions are required almost exclusively. Many adult and elderly patients for whom propranolol is prescribed are also unable to swallow solid dosage forms, leading practitioners to seek alternative dosing options; specifically oral suspensions in the strength that is most appropriate for the patient, using a vehicle that will mask the bitter taste of propranolol powder, while remaining alcohol, sorbitol and sugar-free when required.

A recent study determined the stability of propranolol hydrochloride compounded into a 1-mg/mL suspension using SyrSpend SF and subsequently stored in a low-actinic plastic prescription bottle at room temperature conditions. Six samples were assayed at each specific time point extending to 90 days by a stability-indicating high-performance liquid chromatography method. Based on the data collected, when protected from light at room temperature, the beyond-use date of propranolol hydrochloride in SyrSpend SF was shown to be at least 90 days.

To evaluate the stability of more concentrated propranolol suspensions in a sugar-free, commercially available vehicle after storage at room temperature and under refrigeration for up to 120 days, suspensions of propranolol (2 and 5 mg/mL) were prepared in the sugar-free vehicle (Ora-Blend SF), placed in 100-mL amber plastic prescription bottles, and stored at 25°C and 4°C. Physical compatibility was evaluated in terms of color, taste, precipitation, and pH. Propranolol suspensions 2 mg/mL and 5 mg/mL stored at 25°C maintained at least 94.7% of their initial concentration for 120 days, and suspensions stored at 4°C maintained at least 93.9% of their initial concentration for 120 days. There were no notable changes in pH, and all samples remained physically unchanged except for a slight change in color, around day 70, of suspensions stored at room temperature.

Int J Pharm Compd. 2012 Nov-Dec;16(6):513-5.
Stability of propranolol hydrochloride in SyrSpend SF.
Click here to access the PubMed abstract of this article.

Can J Hosp Pharm. 2013 Mar;66(2):118-24.
Stability of propranolol in extemporaneously compounded suspensions.
Click here to access the PubMed abstract of this article.

Nasal Sprays

Aminocaproic acid and tranexamic acid are antifibrinolytic agents with differing potencies. When patients suffer from recurrent nosebleeds, a nasal spray can be customized to meet each patient’s specific needs.

The Indiana Hemophilia and Thrombosis Center recommends the use of compounded aminocaproic acid nasal spray 250 mg/ml, 1 spray to the affected nostril every 4 hours while awake for 7 days following a nosebleed.


For relief of severe epistaxis, tranexamic acid injection has been applied topically to the nasal mucosa, as a spray or by packing the nasal cavity with a gauze strip that has been soaked in the solution. The NIH is conducting a clinical trial known as North American Study of Epistaxis in HHT (NOSE) and is currently recruiting participants to carefully examine the efficacy and safety of 3 nasal sprays, compared to placebo, for the treatment of HHT (Hereditary Hemorrhagic Telangiectasia) related nosebleeds. As per this study, tranexamic acid can be compounded as a 10% nasal spray, used as 0.1 ml spray in each nostril twice daily for 12 weeks (total dose of tranexamic acid is 40 mg/day).

Read about this clinical study: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4011923/

Epigallocatechin Gallate (EGCG) Offers Protection Against Multiple Pathologies

Arch Oral Biol. 2012 May;57(5):429-35. Epub 2012 Jan 5.
Green tea: a promising natural product in oral health.
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Clin Exp Pharmacol Physiol. 2012 Mar;39(3):265-73. doi: 10.1111/j.1440-1681.2012.05673.x.
Potential role of green tea catechins in various disease therapies: progress and promise.
Click here to access the PubMed abstract of this article.

PLoS One. 2011;6(10):e25224. Epub 2011 Oct 13.
Green tea catechins reduce invasive potential of human melanoma cells by targeting COX-2, PGE2 receptors and epithelial-to-mesenchymal transition.
Click here to access the PubMed abstract of this article.

Skin Pharmacol Physiol. 2009;22(3):137-41. Epub 2009 Feb 12.
Effects of oral epigallocatechin gallate supplementation on the minimal erythema dose and UV-induced skin damage.
Click here to access the PubMed abstract of this article.

Basic Clin Pharmacol Toxicol. 2010 Aug;107(2):669-75. Epub 2010 Mar 22.
(-)-epigallocatechin gallate inhibits endothelin-1-induced C-reactive protein production in vascular smooth muscle cells.
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Curr Mol Med. 2012 February; 12(2): 163–176.
Anti-Cancer Activities of Tea Epigallocatechin-3-Gallate in Breast Cancer Patients under Radiotherapy
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Topical Therapy to Reduce Infantile Hemangiomas

Infantile hemangiomas (IH), also known as “strawberry marks,” are collections of blood vessels caused by increased cell division and growth. A compounded topical “gel-forming solution” containing the medication timolol maleate has been reported as a potentially effective treatment for superficial IH. The best response was achieved with the superficial type of hemangioma, using a solution of 0.5% timolol applied topically twice daily for longer than 3 months. The major advantages of topical timolol are ready availability, cost, ease of administration, and minimal risk of drug-related adverse events.

Pediatr Dermatol. 2012 Jan-Feb;29(1):28-31.
Timolol maleate 0.5% or 0.1% gel-forming solution for infantile hemangiomas: a retrospective, multicenter, cohort study.
Click here to access the PubMed abstract of this article.

Zinc stimulates the immune system and zinc deficiency increases the risk of infections. An analysis of 13 placebo-controlled studies showed strong evidence that adequate doses of zinc may reduce the duration and intensity of the common cold. Three trials used zinc acetate in daily doses of over 75 mg; the pooled results indicated a 42% reduction in the duration of colds. Contradictory results in various studies can largely be explained by the formulation of the lozenges or the variation in the total daily dose of zinc that the person obtained from the lozenges. Zinc lozenges have caused side effects such as bad taste and constipation that stopped when lozenge use was discontinued, and there is no evidence that short term occasional use would cause long term harm. Ask our compounding pharmacist about the most appropriate preparations.

Zinc Lozenges May Shorten the Duration of Colds: A Systematic Review
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This study finds that modified-release sildenafil reduced attack frequency in patients with Raynaud’s phenomenon secondary to limited cutaneous systemic sclerosis and was well tolerated.

Arthritis Rheum. 2011 Mar;63(3):775-82. doi: 10.1002/art.30195.
Modified-release sildenafil reduces Raynaud’s phenomenon attack frequency in limited cutaneous systemic sclerosis.
Click here to access the PubMed abstract of this article.

Topical Glycopyrrolate for Treatment of Hyperhidrosis

Excessive sweating, or hyperhidrosis, is a socially embarrassing disorder and may negatively impact the quality of life. In order of frequency, palmar-plantar, palmar-axillary, isolated axillary, and craniofacial hyperhidrosis are distinct disorders.

Application of topical glycopyrrolate 2% “appears to be effective and safe for the treatment of excessive facial sweating in primary craniofacial and secondary gustatory hyperhidrosis following sympathectomy”.

Ten patients with compensatory sweating after sympathectomy applied one milliliter of a 2% water solution of topical glycopyrrolate once a day over the affected area and massaged for 30 seconds. Eight of the 10 treated patients dramatically improved with the topical application of glycopyrrolate. Two patients quit the treatment due to secondary effects (optical accommodative failure and dry mouth). The results of the study demonstrated that local application of glycopyrrolate might be the treatment of choice for compensatory hyperhidrosis.

“Glycopyrrolate iontophoresis is more effective than tap water iontophoresis in the treatment of palmoplantar hyperhidrosis” and “glycopyrrolate iontophoresis has both local and systemic effects on perspiration”.

Br J Dermatol. 2008 May;158(5):1094-7.
Topical glycopyrrolate for patients with facial hyperhidrosis.
Click here to access the PubMed abstract of this article.

Dermatol Ther. 2008 Sep-Oct;21(5):406-8.
A medical alternative to the treatment of compensatory sweating.
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Australas J Dermatol. 2004 Nov;45(4):208-12.
Iontophoresis with glycopyrrolate for the treatment of palmoplantar hyperhidrosis.
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Lidocaine 8% Intranasal Spray for Trigeminal Neuralgia

Intranasal lidocaine 8% administered by a metered-dose spray produced prompt but temporary analgesia without serious adverse reactions in patients with second-division trigeminal neuralgia.

Br J Anaesth. 2007 Feb;98(2):275
Lidocaine intranasal spray for treatment of trigeminal neuralgia.
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Topical Treatment for Chronic Venous Leg Ulcers, Irritation around Stomas, and Diaper Rash

Daily application of sucralfate gel to non-infected post-phlebitis/vascular ulcers for 42 days led to complete healing in 95.6% of patients compared to only 10.9% of cases that used placebo.

Int J Mol Med. 2008 Jul;22(1):17-23.
Topical treatment of chronic venous ulcers with sucralfate: a placebo controlled randomized study.
Click here to access the PubMed abstract of this article.

A 10% aqueous solution of sucralfate, administered twice daily as a rectal enema or vaginal douche, was also used successfully to treat radiation-induced rectal and vaginal ulcers.

Arch Dermatol. 2000 Oct;136(10):1199-200.
Topical sucralfate for erosive irritant diaper dermatitis.
Click here to access the PubMed abstract of this article.

Ann Pharmacother. 1999 Dec;33(12):1274-6
Treatment of radiation-induced proctitis with sucralfate enemas.
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Topical sucralfate represents a safe, inexpensive and effective therapeutic intervention, particularly for those patients with high output or short stomas where repeated stoma leakage may be unavoidable.

Clin Exp Dermatol. 2000 Nov;25(8):584-8.
Topical sucralfate in the management of peristomal skin disease: an open study.
Click here to access the PubMed abstract of this article.

Low-Dose Naltrexone

Accumulating evidence suggests that Low Dose Naltrexone can promote health supporting immune-modulation which may reduce various oncogenic and inflammatory autoimmune processes. Since LDN can upregulate endogenous opioid activity, LDN may also play a role in healing and repair of tissues, as well as promoting stress resilience, exercise, social bonding, and emotional well-being, and ameloriating psychiatric problems such as autism and depression.

Med Hypotheses. 2009 Mar;72(3):333-7. Epub 2008 Nov 28.
Low-dose naltrexone for disease prevention and quality of life.
Click here to access the PubMed abstract of this article.


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