Compounding Pharmacy Uses

Absorption Enhancement

Topically applied creams and gels can be created with absorption enhancers. Many chemicals need help to get through the protective skin barrier. Examples include ketoprofen (anti-inflammatory), lorazepam (anxiolytic, anti-nauseant), morphine (pain), cyclobenzaprine (muscle relaxant), lidocaine (topical anesthetic), ketamine (pain), and many others.

These links offer some information regarding some of the bases we frequently use. Pluronic Lecithin Organogel (PLO) is made with pluronic gel combined with a lecithin based oil.

PLO gel looks and feels like a cream but is actually a gel. Combining the aqueous phase (pluronic gel) with the lecithin oil base creates an emulsion that holds together due to the surfactant qualities of the pluronic gel and the viscosity of that gel at room temperature. Chilling a PLO will actually make it turn liquid and can allow the gel to separate back into its oil and aqueous phases (usually takes weeks for separation to occur).

DMSO can also be used for some applications. Occasionally, DMSO and PLO are combined in the same product.

Liposomal creams are variations on what has been discussed above. Many compounding specialists (including us) have devised unique proprietary creams specifically designed for different absorption characteristics. This is an art that take years of knowledge and practice.

Adrenal Fatigue/Thyroid Imbalance

The adrenal glands secrete hormones such as cortisol, estrogen, and testosterone that are essential to health and vitality and significantly affect total body function. After mid-life, the adrenal glands gradually become the major endogenous source of sex hormones in both men and women. Intense or prolonged physical or emotional stress commonly associated with modern lifestyles or chronic illness can lead to Adrenal Fatigue, which is an important contributing factor in health conditions ranging from allergies to obesity. Anti-inflammatory and anti-oxidant adrenal hormones like cortisol help to minimize allergic and negative reactions, such as cancer and autoimmune disorders. These hormones closely affect the utilization of carbohydrates and fats, the conversion of fats and proteins into energy, and cardiovascular and gastrointestinal function. Proper adrenal support is essential to complete the hormonal pathway to optimal health, and includes proper nutrition, getting plenty of sleep, regular moderate exercise, stress management, slowing down to regain a proper perspective on life, and replacement of deficient hormones.

Thyroid Hormone Therapy
Symptoms of hypothyroidism (low levels of thyroid hormone) include fatigue, cold and heat intolerance, hypotension, fluid retention, dry skin and/or hair, constipation, headaches, low sexual desire, infertility, irregular menstrual periods, aching muscles and joints, depression, anxiety, slowed metabolism and decreased heart rate, memory impairment, enlarged tongue, deep voice, swollen neck, PMS, weight gain, hypoglycemia, and high cholesterol and triglycerides. Yet, more than half of all people with thyroid disease are unaware of their condition.Although both T4 (thyroxine, an inactive form that is converted to T3 in other areas of the body) and T3 (triiodothyronine, the active form) are secreted by the normal thyroid gland, many hypothyroid patients are treated only with levothyroxine (synthetic T4). Some hypothyroid patients remain symptomatic, and T3 may also be required for optimal thyroid replacement therapy. However, the only commercially available form of T3 is synthetic liothyronine sodium in an immediate release formulation which is rapidly absorbed, and may result in higher than normal T3 concentrations throughout the body causing serious side effects, including heart palpitations. Research indicates there is a need for sustained-release T3 preparations in order to avoid adverse effects.

A randomized, double-blind, crossover study found inclusion of T3 in thyroid hormone replacement improved cognitive performance, mood, physical status, and neuropsychological function in hypothyroid patients. Two-thirds of patients preferred T4 plus T3, and tended to be less depressed than after treatment with T4 alone. Patients and their physicians may wish to consider the use of sustained-release T3 in the treatment of hypothyroidism, particularly when the response to levothyroxine (T4) has not been complete.

J Endocrinol Invest 2002 Feb;25(2):106-9

Rectal Administration of Propylthiouracil for Patients with Thyrotoxicosis and Critical Illness

The Division of Endocrinology and Metabolism, Beth Israel Medical Center, University Hospital and Manhattan Campus for the Albert Einstein College of Medicine, reported the successful management of thyrotoxicosis in a seriously ill 47-year-old man with a perforated gastric ulcer in whom oral intake was contraindicated. Specially prepared suppositories containing 400 mg of propylthiouracil (PTU) were administered rectally every 6 hours. PTU was substantially absorbed from the rectal suppositories, with serum levels of PTU maintained within the high therapeutic range for 5 days until the patient was able to tolerate orally administered therapy. The patient improved clinically during this treatment. They concluded that this case strongly supports the rectal administration of PTU in suppository form as an appropriate alternative route in any patient with thyrotoxicosis, including the critically ill patient, when oral administration is not possible.

Endocr Pract. 2006 Jan-Feb;12(1):43-7.

Rectal administration of propylthiouracil in suppository form in patients with thyrotoxicosis and critical illness: case report and review of literature.

Click here to access the PubMed abstract of this article.

Chronic Fatigue Syndrome (CFS, Chronic Fatigue and Immuno-Deficiency Syndrome, CFIDS) andFibromyalgia (FM, formerly called fibrositis) may manifest as hypothalamic, pituitary, and immune dysfunction.

A study in the Annals of Allergy, Asthma and Immunology [2000 Jun;84(6):639-40] demonstrated that supplementation with NADH for one month resulted in significant improvement, and other studies have shown some minimal improvement with magnesium.

Ann Allergy Asthma Immunol. 1999 Feb;82(2):185-91

Therapeutic effects of oral NADH on the symptoms of patients with chronic fatigue syndrome.

The combination of pituitary dysfunction, high reverse T3, and thyroid resistance, leads to inadequate thyroid effect in most, if not all, CFIDS/FM patients. T4 (levothyroxine) preparations are often ineffective for CFIDS/FM patients. A T4/T3 combination preparation or straight T3 (triiodothyronine) may be preferable. T3 works the best for many of these patients, but Cytomel, a very short acting T3 available at retail pharmacies, is also a poor choice because the varying blood levels cause problems such as heart palpitations.

Compounded, sustained-release T3 may be the best treatment. However, standard blood tests may lead one to dose incorrectly and not obtain significant benefits. Ultimately, it is the expertise and dosing of the T3 or T4/T3 combinations and the makeup of the medications that determines the success of treatment.

Natural Therapies for CFIDS/FM: Proper nutritional supplements, proteins, and hormones can protect and enhance the immune system. Antioxidants may also be beneficial because free radicals play a role in causing damage to the immune system.

Vitamin B-12 levels are often low in patients with CFIDS/FM. A malfunctioning thyroid or adrenal gland can decrease the ability of the body to absorb and utilize vitamin B-12. Vitamin B-12 is necessary for a healthy nervous system; it has been known for many years that depression and fatigue can be caused by low B-12 levels.

D-ribose significantly reduced clinical symptoms in patients suffering from fibromyalgia and chronic fatigue syndrome, with an average increase in energy on the VAS of 45% and an average improvement in overall well-being of 30%.

Androgen Therapy

Improving Sexual Function with Androgen Therapy
Androgen therapy for men and women with sexual dysfunction has been successfully used to restore sexual function for over 80 years in an off-label setting. The FDA has not approved androgen therapy for treatment of male or female sexual dysfunction. The only FDA approved pills for male erectile dysfunction are Viagra and Levitra. The FDA has approved testosterone use only for men with “male hypogonadism” including low interest, osteoporosis,depressed mood, low energy, etc. There are no FDA approved pharmaceutical treatments for women with sexual dysfunction. There are limited long term safety data for use of androgens in women, and there is much to learn. Androgen therapy for men and women for sexual dysfunction is a new field.

Biochemical Facts about Androgens
Androgens are sex steroids which structurally have 19 carbons. All steroids are derived from enzyme breakdown of cholesterol. There are three groups of steroids: mineralocorticoids – synthesized, in part, in the zona glomerulosa of the adrenal gland, corticosteroids – synthesized, in part, in the zona fascicularis of the adrenal gland and sex steroids – synthesized, in part, in the zona reticularis. There are 7 total androgens: dehydroepiandrosterone, delta 5 androstenediol, androsterone, delta 5 androstanediol, delta 4 androstendione, testosterone and dihydrotestosterone. The other sex steroids are estrogens (18 carbons): estradiol, estrone, estriol. Androgens are synthesized in the: gonad (ovary or testicle) from cholesterol; adrenal gland (zona reticularis) from cholesterol and periphery from DHEA. Androgens are sex steroids as natural to women as are estrogens.

Physiologic Facts About Androgens
Androgens have actions on multiple areas of the body including bone, muscle, skin, liver, kidney, brain, immune system, bone marrow and genital organs. Contemporary evidence is accumulating from animal/human studies that androgens are critical for male and female sexual function – desire, arousal, orgasm function. The exact mechanism of action of androgens on the body may involve the synthesis of critical sex steroid dependent proteins or growth factors which act on the nerves, arteries, smooth muscles and connective tissue of the genitals maintaining structure and function.

Epidemiologic Facts About Androgens
Androgen values consistently decrease with age in both genders. By age 40 – 50, men and women have less than half of the DHEA and testosterone they had at age 20 years.

Pathophysiologic Facts About Androgen Insufficiency
There are five major categories or types of etiology of androgen insufficiency: Gonadal (chemo- or radiation-therapy, oophorectomy), Adrenal (adrenal failure or insufficiency), Hypothalamic-Pituitary (hypopituitarism), Drug-Related (corticosteroids, anti-androgenic agents, oral contraceptive pill, oral estrogen therapies) and Idiopathic (age-related).
Androgen insufficiency may be indicative of, or causally related to other medical, psychiatric or psychosocial factors such as (i) a major life stress or relationship conflicts (ii) thyroid disease (i.e. hypo- or hyperthyroidism), (iii) major metabolic/nutritional disorders like iron or vitamin D deficiency or other causes of chronic fatigue like Lyme disease or chronic fatigue syndrome; psychiatric disorders such as major depressive disorder; or other potential etiological conditions or pre-disposing factors which have been implicated including: anorexia nervosa, various immunologic disorders, such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and HIV-AIDS. SHBG (sex hormone binding globulin), a carrier protein produced in the liver, is elevated in many of these syndromes. There is a dilemma with elevated SHBG. The bioavailable form of testosterone is free or unbound testosterone. Free testosterone is equal to the total testosterone divided by the free testosterone. In patients with elevated SHBG values, total testosterone values have to be elevated to even higher values, so that free testosterone values are adequate. In particular, production of SHBG is highly estrogen sensitive – oral intake of estrogen results in a profound dose-dependant INCREASE in SHBG.
Conditions in women where androgen values are associated with decreased activity of critical enzymes include sexual dysfunction after childbirth and sexual dysfunction associated with the transition and the menopause. In women, oral contraceptive medications are associated with decreased ovarian synthesis of testosterone and increased synthesis of SHBG. In women, estrogen medications are associated with increased synthesis of SHBG. In women, lupron, Zoladex medications are associated with decreased ovarian synthesis of testosterone.

Therapy Guidelines and Adverse Effects
Androgen therapy demands a clear indication. No patient is too old if indicated. For men, digital rectal examination and PSA blood tests are mandatory if the patient is older than 40. In women, estrogen levels are indicated. Androgen therapy is contraindicated in men and women with breast and prostate cancer. In men, androgen therapy is contraindicated in severe LUTS (lower urinary tract symptoms). In women, androgen therapy is contraindicated in pregnancy. All patients on androgen therapy should have a quarterly follow-up in the first year. Clinical and biochemical changes (androgens, estrogens, SHBG, LH, FSH, prolactin, CBC, LFT’s, lipid profile) are useful in establishing best dosing regimen. Given the paucity of long-term, controlled trials, patients should be fully informed of potential risks and carefully monitored for potential adverse reactions. Potential side effects of androgen therapy for women include acne, weight gain, excess facial and body hair, permanent lowering of the voice, and adverse lipid changes. Based on available clinical trial data, and the 4-year experience at the Center for Sexual Medicine, these side effects are infrequent if androgen levels are maintained within normal physiological ranges and the delivery system of androgen administration is via topical testosterone therapy. Lowered HDL cholesterol, increased hematocrit levels, and abnormal liver function tests have been reported with certain oral or intramuscular testosterone preparations. Potential virilization of a female fetus is a serious risk in reproductive-aged women.

More research in the field of male and female sexual dysfunction is needed.

Andropause

Androgen deficiency in the aging male (ADAM), also known as andropause, affects an estimated 1 in 200 men. Symptoms of testosterone deficiency may include:

  • weakness
  • fatigue
  • reduced libido
  • osteoporosis

A man may be considered hypogonadal at any age if total testosterone is less than 200 ng/dl, or bioavailable testosterone is less than 60 ng/dl. Basaria and Dobs of Johns Hopkins University recommend that elderly men with symptoms of hypogonadism and a total testosterone level < 300ng/dl should be started on hormone replacement.

Testosterone vs. Synthetics
What is the Optimal Form of Testosterone for Replacement Therapy?

Testosterone USP is natural bio-identical testosterone that has been approved by the United States Pharmacopoeia and is available as a bulk chemical. Upon a prescription order, compounding pharmacists can use Testosterone USP to prepare numerous dosage forms. Natural Testosterone Replacement is Central to the Treatment of All Facets of Andropause. The term “testosterone” is often used generically when referring to numerous synthetic derivatives, as well as natural bio-identical testosterone. Confusion is responsible for conflicting data in the medical literature about the benefits and risks of testosterone therapy. Studies must be reviewed carefully to determine the form of testosterone that was used.

Natural testosterone must not be confused with synthetic derivatives or “anabolic steroids,” which when used by athletes and bodybuilders have caused disastrous effects. For example, administration of synthetic nonaromatizable androgens, like stanozolol or methyltestosterone, causes profound decreases in HDL-C (“good cholesterol”) and significant increases in LDL-C (“bad cholesterol”). Yet, hormone replacement with aromatize androgens, such as testosterone, results in lower total cholesterol and LDL cholesterol levels while having little to no impact on serum HDL cholesterol levels. Proper monitoring of laboratory values and clinical response are essential when prescribing testosterone replacement therapy.

The only absolute contraindications to androgen replacement therapy are the presence of prostate or breast cancer. “Although it is known that the clinical course of prostate cancer is accelerated by testosterone, its incidence is not increased by [testosterone] administration… There is even no clear evidence that testosterone replacement accelerates the development of BPH.”

Drugs & Aging 1999 Aug;15(2):131-42

Goals of Testosterone
Goals of Testosterone Replacement Therapy in Adult Hypogonadal Men (age 50 or older):

  • Improvement in psychological well-being and mood
  • Improvement in erectile dysfunction
  • Improvement in libido
  • Increased muscle mass
  • Increased strength and stature
  • Preservation of bone mass
  • Possible decrease in cardiovascular risk

A man may be considered hypogonadal at any age if total testosterone is less than 200 ng/dl, or bioavailable testosterone is less than 60 ng/dl. Basaria and Dobs of Johns Hopkins University recommend that elderly men with symptoms of hypogonadism and a total testosterone level < 300ng/dl should be started on hormone replacement.

Supporting Literature
Administration of a transdermal testosterone (T) gel formulation to hypogonadal men provided dose-proportional increases in serum T levels to the normal adult male range. Testosterone 1% gel (50 or 100 mg/day) was compared to the permeation-enhanced T patch. After 180 days, skin irritation was reported in 5.5% of subjects treated with T gel and in 66% of subjects in the permeation-enhanced T patch group. This research at UCLA concluded that T gel replacement improved sexual function and mood, increased lean mass and muscle strength (principally in the legs), and decreased fat mass in hypogonadal men with less skin irritation and discontinuation compared with the recommended dose of the permeation-enhanced T patch.

Bio-Identical Hormone

Hormone Replacement Therapy
Men: Here is your link: Natural Testosterone Replacement

Ladies: If you know that you want Bio-Identical hormone therapy, click this link: Natural Hormone Replacement for Women. If you are undecided, read on…

Risks vs. Benefits of:
Hormone Replacement Therapy and The Advantages of Bio-Identical HRT

The Women’s Health Initiative study was designed to identify the potential risks and benefits of Hormone Replacement Therapy (HRT). A portion of the clinical trial was stopped early after results showed that a synthetic hormone combination increased the women’s risks of developing invasive breast cancer, heart disease, stroke, and blood clots. The data and safety monitoring board concluded that the risks of using a synthetic estrogen – synthetic progestin drug combination outweighed the benefits.

It is interesting that the researchers considered this finding to be “news”. In fact, many published clinical trials have already reported that the risk of breast cancer is increased by long-term use of conjugated equine estrogens and further increases when the synthetic progestin medroxyprogesterone acetate is added to the regimen.

At our pharmacy, we compound customized bio-identical hormones including estriol, estrone, estradiol, progesterone, and testosterone, using the exact dose of the specific bio-identical hormones needed by each woman in the most appropriate dosage form for that individual. This customization allows the prescriber to maximize the therapeutic benefits that can be obtained through the use of bio-identical hormones while minimizing the potential for adverse effects.

Bio-identical hormones were NOT used in the WHI study. Bio-identical hormones are structurally identical to hormones that are naturally produced by the human body and intended to replace these hormones when their levels decline either as a consequence of aging, disease, or surgery. Research has shown that bio-identical hormones can effectively control symptoms of menopause, including hot flashes, insomnia, vaginal dryness, and frequent urinary tract infections. Women’s experiences and clinical outcomes of HRT differ vastly depending on whether the hormones are synthetic or bio-identical, the dose, dosage form, and route of administration. For years, physicians have been prescribing bio-identical HRT for women who have experienced problems or have other concerns about the use of synthetic hormones.

Progesterone is a term that is incorrectly used interchangeably to describe both natural bio-identical progesterone and synthetic substitutes. Synthetic progestins (also called progestogens or progestational agents) are derivatives of bio-identical progesterone and have been developed because they are longer-lasting, more potent, and patentable. Although synthetic progestins such as medroxyprogesterone acetate are clearly beneficial in preventing estrogen-induced overgrowth of the uterine lining and endometrial cancer, their other effects may be less desirable. Medroxyprogesterone can negate the beneficial effects of estrogen on lipid profiles, atherosclerosis, and vascular reactivity. Natural progesterone, on the other hand, can maintain the benefits of estrogen on cholesterol while minimizing the side effects associated with synthetic progestins.

According to some studies, medroxyprogesterone may reduce the dilatory effect of estrogens on coronary arteries, increase the progression of coronary artery atherosclerosis, increase the clot-forming potential of atherosclerotic plaques, promote insulin resistance and consequent hyperglycemia (high blood sugar), and may significantly lower high-density lipoproteins (HDL, “good cholesterol”), thereby decreasing the cardioprotective benefit of estrogen therapy. Studies at Wake Forest University School of Medicine have concluded that synthetic medroxyprogesterone, in contrast to bio-identical progesterone, increases the risk of coronary vasospasm. Bio-identical progesterone plus estradiol protected against vasospasm.

The benefits of progesterone are not limited to prevention of endometrial cancer in women who are receiving estrogen replacement. Progesterone can build bone density, promote glucose utilization, and improve sleep patterns. Mayo Clinic researchers surveyed 176 women taking natural micronized progesterone who had previously taken synthetic progestins. After one to six months, the women reported an overall 34% increase in satisfaction on micronized progesterone compared to their previous HRT, reporting these improvements: 50% in hot flashes, 42% in depression, and 47% in anxiety. Micronized progesterone was also more effective in controlling breakthrough bleeding. When considering treatment options for preventing heart disease and osteoporosis and relieving menopausal symptoms, it is important to address not only benefit-versus-risk ratios but also quality-of-life. A woman’s need for HRT may transcend statistics of heart disease, osteoporosis, and cancer. Without HRT, many women (and consequently, their families) feel totally miserable, exhausted, and unable to cope. Yet, only 20% of women continue to take synthetic hormones after two years, mainly due to the development of side effects. The quality of many women’s lives has been dramatically improved through the use of bio-identical HRT.

Statistics and fear abound, yet the absolute risk of cancer attributable to HRT remains low, and the risk of some forms of cancer is reduced. For example, an analysis of 18 studies involving thousands of women concluded that the risk of developing colorectal cancer is reduced by 34% in current estrogen users.

Decisions about whether to stop, start, or change your HRT should make on an individual basis only after consulting your physician and a knowledgeable pharmacist. Our goal is to work together with physician and patient to solve medication problems and optimize each patient’s health and well-being.

Studies and the media continue to provide conflicting and confusing information. We are here to help clarify the issues that surround HRT.

Your questions are welcome.

Dentistry

We work together with dentists and their patients to solve problems using customized medications.

Upon a prescription order, we can compound:

  • lip balms for viral lesions
  • topical muscle relaxants/analgesics
  • topical anesthetics
  • non-staining antibacterial rinses
  • oral sedation in lollipops and freezer pops
  • lollipops for oral thrush
  • mouth rinses for aphthous ulcers or chemotherapy-induced stomatitis
  • mouth rinse to stop oral bleeding during dental procedures for patients who take anticoagulants
  • dry socket preparations
  • “mucosal bandages” to cover ulcerated, infected, or tender mucosa
  • lozenges that help to prevent gagging
  • and many more unique preparations and novel delivery systems

Medications are manufactured in a limited number of strengths and dosage forms that will satisfy the needs of most patients due to stability concerns, and the cost of stocking and distributing numerous formulations of each drug. Using pharmaceutical grade chemicals and specialized equipment not found in most pharmacies, we can compound medications in doses and dosage forms that are not commercially available. We want to optimize the care of every patient. Just let us know what you need!

Dermatology

Enexia Specialty offers a variety of advanced skin care products to treat, correct and prevent various dermatological conditions. Whether your practice treats skin diseases (i.e. Psoriasis, Eczema, Cancers, Acne, Rosacea, alopecia, warts) or cosmetic dermatology (i.e. Anti-aging, Laser treatments, chemical peels, Acne, Rosacea), Enexia Specialty has compounds to fit each type of practice.

Through our unique relationship with dermatologists, plastic surgeons, aestheticians and other skin-care professionals, we continue to expand our knowledge of skin and skin health with specialized treatment options. We can prepare gels, creams, ointments, solutions, occlusive pastes, and anything else you can think up to creatively treat your patients.

Below is a sample of compounded products for our dermatology practitioners.

Triamcinolone with Camphor, Menthol and/or Phenol
For pruritus, especially for chronic cases.

GROOT Cream
For bleaching and tightening, especially of the face.

Sal-acid, Mandelic, Glycolic, Lactic or Trichloroacetic Acids
For in-office chemical peels.

Lactic and/or Salicylic Acids
For wart removal, delivered in a water-resistant, flexible, occlusive base.

Anti-Infectives 
(Metronidazole, Ketoconazole, Itraconazole, Fluconazole, Amphotericin) For any topical infections of the skin, nails, scalp, and/or mucous membranes

Anesthetics 
(Lidocaine, Tetracaine, Benzocaine, Prilocaine)For anesthesia due to pain or for use prior to a procedure. Combinations of creams (i.e. Benzocaine, Lidocaine and Tetracaine) can also be compounded.

Anti-Inflammatories 
(Ketoprofen, Ibuprofen, Diclofenac) Available in various topical delivery systems and customized dosages

Retinoic Acid
Available in customized strengths from 0.001% to 0.4%

Hydroquinone
Available in various strengths up to 10%

Hydrocortisone
Available in concentrations from 0.1% to 20%

Anesthetics 
(Lidocaine, Tetracaine, Benzocaine, Prilocaine)For anesthesia due to pain or for use prior to a procedure. Combinations of creams (i.e. Benzocaine, Lidocaine and Tetracaine) can also be compounded.

Anti-Inflammatories 
(Ketoprofen, Ibuprofen, Diclofenac) Available in various topical delivery systems and customized dosages.

Retinoic Acid
Available in customized strengths from 0.001% to 0.3%

Hydroquinone
Available in various strengths up to 10%

Hydrocortisone
Available in concentrations from 0.1% to 20%

Dosage Forms

We prepare many different dosage forms depending on physicians desires and patient needs. Creams, gels, and ointments

We suggest an airless pump dispenser for many creams and gels. They are convenient (compliance enhancement) and consistent (accurate). These dispensers are also handy for travel. Ointments are usually too thick for this type of delivery device.

We also use convenient topical syringes. These are especially useful for very small doses. An example would be female testosterone at the rate of 2 mg per 0.1 ml of gel. Pain and nausea medication can also be applied in this way to allow patient or caregiver to easily titrate dose based on need. Sizes range from 0.5 ml to 60ml.

Heat sealed tubes are also available in sizes from 3 Gm up to 240 Gm.

Suppositories
We usually prepare suppositories in a heat sealed pull apart shell. These are especially convenient for products such as indomethacin and progesterone. Patients and caregivers find these easy to use and damage to the suppository during removal are. Good for rectal or vaginal applications.

Capsules
We also prepare slow release dry powder capsules. A few examples include triiodothyronine, DHEA, Pregnenolone, melatonin, and hydrocortisone.

Sublingual lozenges (troches)
Our favorite lozenge is a tiny half-moon shaped creation that is comfortable under the tongue (almost unnoticeable due to shape and size). This can be used for testosterone, estrogens, selegiline/ergotamine, melatonin and other items that do not require large amounts of dry chemicals. We have successfully made progesterone and other products up to 50 mg in this form but would not suggest more powder than that for these small lozenges. We also make medium to large lozenges when required. To learn more about lozenges, click one or both of these links: general lozenge information or technical lozenge information.

Sublingual drops
We prepare many natural hormones in a sublingual liquid. We provide handy oral syringes for accurate dosing and use sweeteners such as stevia, xylitol, and glycerin to sweeten without risk to the teeth. This is usually the least expensive way to dose natural hormones because it is the least time-consuming process for us to make and because the required amount of medication is usually 1/2 to 1/4 the amount required for oral dosing.

NOTE: There is one problem regarding sublingual drops or lozenges. Saliva testing for hormones levels can not be accurately done with this type of dosing.

Lollipops
We can make sucrose-free lollipops using a sorbitol base that can include chemicals such as nicotine for smoking cessation, oral anesthetics for mouth or throat pain, and several different formulations for controlling nausea.

Sprays
We prepare nasal and throat sprays using convenient pump dispensers that deliver a consistent dose. We prepare such things as xylitol/beclomethasone, a snore stopper with uvula sprayer and others.

Ophthalmic drops
Prepared in a clean room and put into sterile dropper bottles of various sizes.

Vials containing sterile injections
We use a clean room with a laminar flow hood to prepare products such as trimix (phentolamine/ papaverine/ prostaglandin E-1) for penile injection (erection aid).

Pain Management/Topical Pain Prep

Pain management is essential because even when the underlying disease process is stable, uncontrolled pain prevents patients from working productively, enjoying recreation, or taking pleasure in their usual roles in the family and society. Chronic pain may have a myriad of causes and perpetuating factors, and therefore can be much more difficult to manage than acute pain, requiring a multidisciplinary approach and customized treatment protocols to meet the specific needs of each patient.

Optimal treatment may involve the use of medications that possess pain-relieving properties, including some antidepressants, anticonvulsants, antiarrhythmics, anesthetics, antiviral agents, and NMDA (N-methyl-D-aspartate) antagonists. NMDA-receptor antagonists, such as dextromethorphan and ketamine, can block pain transmission in dorsal horn spinal neurons, reduce nociception, and decrease tolerance to and the need for opioid analgesics. [Anesth Analg 2001 Mar;92(3):739-44] By combining various agents which utilize different mechanisms to alter the sensation of pain, physicians have found that smaller concentrations of each medication can be used.

Topical and transdermal creams and gels can be formulated to provide high local concentrations at the site of application (e.g., NSAIDs for joint pain), for trigger point application (e.g., combinations of medications for neuropathic pain), or in a base that will allow systemic absorption. Side effects associated with oral administration can often be avoided when medications are used topically. Studies suggest that there are no great restrictions on the type of drug that can be incorporated into a properly compounded transdermal gel. When medications are administered transdermally, they are not absorbed through the gastrointestinal system and do not undergo first-pass hepatic metabolism.

We work together with patient and practitioner to solve problems by customizing medications that meet the specific needs of each individual. Please contact our compounding pharmacist to discuss the dosage form, strength, and medication or combination that is most appropriate for your patient.

Pediatric Compounding

When it comes to medicating your child, sometimes one size, dosage form, or flavor does not fit all. That’s when it’s time for you and your physician to call Enexia Specialty. When the need arises,  Enexia Specialty can custom make your child’s medication to meet his or her individual needs.

Many children have difficulty swallowing capsules or tablets. Pediatricians and compounding pharmacists can work together to find alternative dosage forms for children. These include lollipops, syrups, freezer pops, lozenges, gummies, even pacifiers and baby bottles for infants.

For infants, we even have a number of compounding for various conditions diaper rash formulas.

Diaper Rash
Nystatin 0.758% Karaya Gum 33% Topical Ointment
Cholestyramine 5% Diaper Rash Ointment
Happy Hiney
Buttocks Ointment
Zinc Oxide 5%/Benzoin Compound Topical Paste

Cough/Cold
Menthol 0.1%/Eucalyptus 0.275% Sorbitol LollipopTM Base

This tastes similar to commercial cough drops except in the convenience of a lollipop dosage form. One advantage of a lollipop is that it can last a long time if it is sucked on for a while and the rest saved.

Ear Infections
Oral xylitol is often requested for patients with chronic ear infections.
Xylitol 2 Gm Sorbitol LollipopTM Base

Fever
Ibuprofen Suppository – Ibuprofen is not commercially available as a suppository although acetaminophen is.
Ibuprofen 100 mg Sorbitol LollipopTM Base
Acetaminophen 240 mg Sorbitol LollipopTM Base
Ibuprofen 10% in LipodermR Transdermal Gel

Lice
Ivermectin 1% Topical Lotion
Aromatic Head Lice Formula
Lice Remedy, Essential Oils

Eczema
Hydrocortisone Acetate 0.2% Topical Cream
Cyanocobalamin 0.07% Topical Cream
Cyanocobalamin 0.1% Topical Foam

Chicken Pox
Oatmeal/Allantoin Lotion
Oatmeal/Calamine/Pramoxine Hydrochloride Lotion
Diphenhydramine HCl 1%/Calamine 8% Topical Cream
Diphenhydramine HCl 2%/Hydrocortisone 0.5% Topical Cream
Lidocaine HCl 1%/Tetracaine HCl 1% Topical Foam

Topical Anesthetics
All of these drugs have a quick onset of action. Prilocaine/lidocaine is often used in offices, however, the onset is longer so the patient must wait.

Lidocaine HCl 4%/Tetracaine HCl 0.5%/Epinephrine HCl 0.05%
Topical Gel
Lidocaine HCl 1%/Tetracaine HCl 1% Topical Foam

Nausea & Vomiting
Ondansetron 4 mg/0.1 mL
Ginger Root 200 mg Sorbitol Lollipop BaseTM
Promethazine HCl 50 mg/mL Topical LipodermR (Stabilized)
Promethazine HCl 25 mg/mL Topical LipodermR

Acne
Parents are often looking for alternatives for acne for their teenagers. Physicians often inquire about non-antibiotic treatments.

Niacinamide 3%/Lipoic Acid 0.5% Topical Cream
Niacinamide 4% Acne Gel
Niacinamide 4%/Biotin 0.1%/Lipoic Acid 0.5% Topical Acne Gel, Alternate

Suspensions
Omeprazole 2 mg/mL Oral Suspension
Lansoprazole 3 mg/mL Oral Suspension
Sildenafil Citrate 1 mg/mL Oral Suspension

Scar Therapy

We make every effort to fill your prescriptions promptly, and we’re glad to take the time to answer questions about your medications and other health concerns. Over the years, we have learned that knowing you better helps us meet your needs, and keep you healthy.

Take a look at our Unique Service

  • Free Prescription Delivery
  • Low-Cost Prescription

About our Pharmacist
Our Registered Pharmacist is here to serve your needs, answer your questions, having a great understanding of pharmacy. Your well-being and satisfaction is of paramount importance to her.

It’s Simple, here are a few reasons!!!

Our Registered Pharmacist has years of experience working for several major chain pharmacies as a Pharmacist, so she has the experience of a major chain pharmacy and the customer service skills of a mom and pop store.

We offer low prescription prices, and on top of that we offer everyday coupons so you can save even more on your prescription.

We treat all our customers like a V.I.P customer, so you don’t get the feeling that your just a number, like at the major pharmacy chains.

Because our overhead is low, we can offer prescriptions at rock bottom prices, unlike other major pharmacy chains.

Sexual Intimacy

Falling in love brings all sorts of chemical reactions to the human body and mind. Increased endorphins, the rush of adrenaline, a release of pheromones and an overall sensation of feeling energized and vibrant. But over time that may not be enough and we may need to supplement the body’s own abilities to achieve desire, arousal, and reliable sexual performance with science and medicine. Aging, childbirth trauma, inevitable hormone decline, pelvic vaginal muscle atrophy from disuse, decreased genital blood flow and genital nerve impairment all take their toll. Assisting health promoting sexual intimacy with hormones, vasodilators, and neural stimulants can restore and sustain arousal, desire, and a gratifying sexual response for the course of our lifetimes. Large studies have proven that intimacy and loving sexuality go hand in hand with good health and a longer life.

Disturbances of sexuality frequently combine both psychological and physical aspects. All too often it is assumed that psychological causes exclusively are to blame, when there are objective, identifiable and readily treatable physical components. Treatment can result in improved health, happiness and quality of life.

Female sex enhancement protocol – pharmaceutical intervention

Estriol vaginal cream if dryness or painful intercourse is involved. We have had great luck with 0.5mg intravaginally nightly for 14 days then 2 or 3 times weekly to maintain.
Lowers vaginal pH to decrease infections, increases vaginal fluids, increases integrity of vaginal wall.

Natural Testosterone to labia daily for 30 days then to inner wrist to maintain.
Dosage range 2 to 6mg daily. Should be in absorption enhancement cream.

Balanced Bio-Identical Hormone Replacement Therapy
In addition to testosterone, estrogen and progesterone need to be in balance

Male sex enhancement protocol – pharmaceutical intervention

Restore Testosterone to more youthful levels to promote libido, enthusiasm, confidence, and sense of well being.
Topical doses ranging from 25mg to 100mg (or more) usually twice daily.

Oral Medications to facilitate erection
Viagra, Cialis, Levitra or sublingual lozenge made from Viagra

Penile Injections to facilitate erection
Combinations of papaverine, phentolamine and/or prostaglandin E1. Also known as Alprostidil, Bi-Mix, Tri-Mix and Quad-Mix

Elimination of or alternative choices for SSRI type medications. Also consider blood pressure medications- especially beta blockers.

Sterile Products

At Enexia Specialty, all sterile compounded preparation are prepared in a ISO 7 Class Clean Room containing a Laminar Airflow Hood. Our pharmacists have specialized training in aseptic technique and compounding and follow strict aseptic procedures.

All sterile compounding is performed by a pharmacist who is responsible to make sure every aspect of sterile compounding, from the proper storage of chemicals to sterility testing of the finished product, is followed according to aseptic protocol.

Sterility testing is done on all of our sterile compounds, designated as “high risk” by the United States Pharmacopoeia, prior to being dispensed to the patient. All testing is documented and maintained on file, which can give the physician confidence in the quality of our sterile preparations.

Veterinary Compounding

At Enexia Specialty, we know how much your pets mean to you. After all, they’re part of the family. And because they’re part of the family, your pets deserve the best medical care available. Whether it’s an emergency or regular preventative treatment, we are the best choice for your quality veterinary compounding needs.

To date, our pharmacy has produced a wide variety of compounded medications including capsules, liquids, flavored chews, transdermal gels, creams, otics, and suppositories. The following are some lists of the drugs we have been getting requests for compounding.

One-Stop Shopping for Your Veterinary Needs

  • Acepromazine
  • Acetylcysteine
  • ACTH (Corticotropin)
  • Acyclovir
  • Aluminum Hydroxide
  • Amitraz (Like Mitaban)
  • Amitriptyline
  • Amlodipine
  • Anti-Diarrheal-A (Like-Amforal)
  • Anti-Diarrheal-D (Like Diathal)
  • Apomorphine
  • Azithromycin
  • Bethanechol
  • Buspirone
  • Calcitriol
  • Carbenacillin
  • Carvedolol
  • Chloramphenicol
  • Chlorpromazine
  • Cimetadine
  • Ciprofloxacin
  • Cisapride
  • Clomipramine
  • Cyclosporine
  • Cyproheptadine
  • DES (Diethylstilbestrol)
  • Desmopressin
  • Dexamethasone
  • Diazepam
  • Diazoxide
  • Diphenhydramine
  • Dipyrone
  • Doxycylcine
  • Enalapril
  • Enrofloxacin
  • Etodolac
  • Famotidine
  • Fluconazole
  • Fludrocortisone
  • Fluoxetine
  • Flutamide
  • Furosemide
  • Gabapentin
  • Glipizide
  • Glutathione
  • Iopanoic Acid
  • Itraconazole
  • Ketoconazole
  • K-O-T Drops
  • Griseofulvin
  • Hydroxyzine
  • Idoxuridine
  • Interferon
  • L-Carnitine
  • Leuprolide Acetate
  • Liquichlor
  • L-Lysine
  • Lufenuron
  • Lysodren (Mitotane)
  • Methimazole
  • Methocarbamol
  • Metoclopramide
  • Metronidazole
  • Neomycin
  • Niacinamide
  • Ondansetron
  • Oxytetracyline OPH
  • Pergolide
  • Phenoxybenzamine
  • Piroxicam
  • Potassium Bromide Praziquantel
  • Prednisoline Acetate
  • Prednisolone
  • Prochlorperazine
  • Progesterone
  • Propantheline Bromide
  • Protamine Zinc Insulin (PZI)
  • Pyrantel Pamoate
  • Ronidazole
  • SAM-e
  • Selegiline
  • Sotolol
  • Taurine
  • Terbinafine
  • Terbutaline
  • Tramadol
  • Triamcinolone
  • Trilostane
  • Tylosin
  • Ursodiol
  • Vitamin K

Unavailable Medications

The list below is updated monthly based on information on the FDA Drug Shortages webpage. A more extensive list that is updated in an ongoing manner can be found here.

Medications may be commercially unavailable for a variety of reasons, the most common being:

  • back-ordered due to a manufacturing problem
  • discontinued due to decreased usage or declining manufacturer          profits, which may be related to the introduction of a newer drug

(Note: Drugs are also withdrawn from the market due to health risks, and we do not compound medications that were discontinued due to safety concerns.)

Sometimes only certain doses and dosage forms of a particular drug, or specific combinations are discontinued.

Our professional pharmacists can help by obtaining the Active Pharmaceutical Ingredient (API) and compounding the needed drug in the most appropriate dose, dosage form, and flavor for each patient. We can also compound medications that are free of problem-causing additives such as sugar, alcohol, preservatives, dyes, and gluten. We utilize the finest FDA approved chemicals, follow current USP guidelines, and are licensed and regulated by our State Board of Pharmacy.

Shortages of Oral and Topical Medications
Liotrix (Thyrolar) Tablets
Mupirocin Ointment
Reserpine Tablets
Sumatriptan Nasal Spray
Theophylline Extended Release Capsules and Tablets
Tretinoin Capsules

Shortages of Veterinary Medications 
Cisapride
Clomipramine
Colchicine
Ketoconazole
Penicillamine
Prednisolone
Selegiline
Ursodiol

Shortages of Injections, Ophthalmic Preparations, and other Sterile Medications:
Ammonium Chloride Injection 
Atropine Sulfate Injection
Caffeine Anhydrous (125mg/mL); Sodium Benzoate (125mg/mL) Injection
Calcium Chloride Injection
Calcium Gluconate Injection 
Dexamethasone Sodium Phosphate Injection
Dextrose Injection
Epinephrine Injection
Fentanyl Citrate Injection
Leucovorin Calcium Injection
Lidocaine HCI Injection
Methylprednisolone Sodium Succinate Injection
Potassium Chloride Injection 
Sodium Acetate Injection 
Sodium Bicarbonate Injection
Sodium Chloride Injection
Tobramycin Injection
Vancomycin HCl for Injection

Discontinued Medications:
Achromycin® Ointment
Actifed®, Actifed-C® Liquid
Azulfidine Liquid
Butazolidin
Cafergot®
Chlorpromazine Oral Solution and Suppositories
Chlortrimeton® Solution
Cortef® Suspension
Cromolyn 
Decaspray®
Desonide® Otic
Dexamethasone - various
Dilantin® Suspension
Hydergine® Liquid
Indomethacin Suppositories
Isoniazid Liquid 
Levsin®/Pb
Meclan® Cream
Midrin®
Minocycline Suspension
Mycelex-G® Vaginal Tablets
Negatan®
Nystatin Suspension
Nystatin Vaginal Tablets
Paregoric
Robaxisal®
Thioridazine Suspension
Topicycline®
Triamcinolone Acetonide 
Trimethobenzamide Suppositories
Vancomycin Liquid
Whitfield’s Ointment 

In addition to the above, there are countless products and “remedies” that are no longer commercially available, but that physicians and patients report are very useful in treating a specific problem. Ask our compounding pharmacist for more information.

Hormone Replacement for Women

Structural differences exist between human, synthetic and animal hormones. In order for a replacement hormone to fully replicate the function of hormones which were originally naturally produced and present in the human body, the chemical structure must exactly match the original. There are significant differences between hormones that are natural to humans and synthetic or horse preparations. Side chains can be added to a naturally-occurring hormone to create a synthetic drug that can be patented by a manufacturer. A patented drug can be profitable to mass produce, and therefore a drug company can afford to fund research as to the medication's use and effectiveness. However, naturally-occurring substances can not be patented, so scientific studies are less numerous on natural hormones, because medical research is usually funded by drug companies.

Natural hormones include estrone (E1), estradiol (E2), progesterone, testosterone, dehydroepiandrosterone (DHEA), and pregnenolone. Our compounding pharmacists work with patients and practitioners to provide customized hormone therapy that provides the needed hormones in the most appropriate strength and dosage form to meet each woman's specific needs. Hormone therapy should be initiated carefully after a woman's medical and family history has been reviewed. Every woman is unique and will respond to therapy in her own way. Close monitoring and adjustments are essential.

Dr. Kent Holtorf is a leading authority in the field of hormone replacement therapy, and is also a board examiner for the American Board of Anti-Aging Medicine (ABAAM).

Click here to read Dr. Holtorf’s article about the benefits of customized hormone therapy.

Estrogens actually refers to a group of related hormones, each with a unique profile of activity. Under normal circumstances, a woman's circulating estrogen levels fluctuate based on her menstrual cycle. For Hormone Replacement Therapy, these hormones are often prescribed in combination to re-establish a normal physiologic balance. The three main estrogens produced in female humans are:

  • E1 (Estrone; 10-20% of circulating estrogens) is the primary estrogen produced after menopause.
  • E2 (Estradiol; 10-30% of circulating estrogens) is the most potent and major secretory product of the ovary, and the predominant estrogen produced before menopause.
  • E3 (60-80% of circulating estrogens)

Progesterone is a term that is incorrectly used interchangeably to describe both progesterone which is "chemically identical" to what the body naturally produces, and synthetic derivatives. Synthetic progestins are analogues of progesterone, and have been developed because they are patentable, more potent, and have a longer duration. Medroxyprogesterone acetate, the most commonly used synthetic progestin, was shown in a large study to cause significant lowering of HDL "good" cholesterol, thereby decreasing the cardioprotective benefit of estrogen therapy. Side effects are a frequent cause for discontinuation of HRT. Only about 20% of women who start synthetic HRT remain on it two years later.

Progesterone:

  • is commonly prescribed for perimenopausal women to counteract "estrogen dominance" which occurs when a woman produces smaller amounts of progesterone than normal relative to estrogen levels.
  • alone, or combined with estrogen, may improve Bone Mineral Density.
  • minimizes the risk of endometrial cancer in women who are receiving estrogen.
  • is preferred by women who had previously taken synthetic progestins.

The benefits of progesterone are not limited to prevention of endometrial cancer in women who are receiving estrogen replacement. Progesterone therapy is not only needed by women who have an "intact uterus", but is also valuable for women who have had a hysterectomy. Vasomotor flushing is the most bothersome complaint of menopause, and is the most common reason women seek HRT and remain compliant. For over 40 years, estrogens have been the mainstay of treatment of hot flashes, but progesterone may be effective as well.

Androgens are hormones that are important to the integrity of skin, muscle, and bone in both males and females, and have an important role in maintaining libido. Declines in serum testosterone are associated with hysterectomy, menopause, and age-related gender-independent decreases in DHEA and DHEA-sulfate. DHEA (dehydroepiandrosterone) is an androgen precursor from which the body can derive testosterone. After menopause, a woman's ovaries continue to produce androgens; however, the majority of the androgens produced in the female body, even before menopause, come from peripheral conversion of DHEA. As the body ages, production of DHEA declines so that by the time a woman goes through menopause, the production of DHEA is often inadequate. Additionally, ERT may cause relative ovarian and adrenal androgen deficiency, creating a rationale for concurrent physiologic androgen replacement. Recently, attention has turned to the addition of the androgens to a woman's HRT regimen in order to alleviate recalcitrant menopausal symptoms and further protect against osteoporosis, loss of immune function, obesity, and diabetes.

Androgens, such as testosterone and DHEA:

  • enhance libido.
  • enhance bone building (increase calcium retention).
  • provide cardiovascular protection (lower cholesterol).
  • improve energy level and mental alertness.

Hormone Replacement for Men

What is the Optimal Form of Testosterone for Replacement Therapy?

Testosterone USP is natural testosterone that has been approved by the United States Pharmacopoeia and is available as a bulk chemical. Upon a prescription order, compounding pharmacists can use Testosterone USP to prepare numerous dosage forms.

The term "testosterone" is often used generically when referring to numerous synthetic derivatives, as well as natural testosterone. Confusion is responsible for conflicting data in the medical literature about the benefits and risks of testosterone therapy. Studies must be reviewed carefully to determine the form of testosterone that was used. Natural testosterone must not be confused with synthetic derivatives or "anabolic steroids," which when used by athletes and body builders have caused disastrous effects. For example, administration of synthetic non-aromatizable androgens, like stanozolol or methyltestosterone, causes profound decreases in HDL-C ("good cholesterol") and significant increases in LDL-C ("bad cholesterol"). Yet, hormone replacement with aromatizable androgens, such as testosterone, results in lower total cholesterol and LDL cholesterol levels while having little to no impact on serum HDL cholesterol levels. Proper monitoring of laboratory values and clinical response are essential when prescribing testosterone replacement therapy.

The only absolute contraindications to androgen replacement therapy are the presence of prostate or breast cancer. "Although it is known that the clinical course of prostate cancer is accelerated by testosterone, its incidence is not increased by [testosterone] administration... There is even no clear evidence that testosterone replacement accelerates the development of BPH."

Drugs Aging. 1999 Aug;15(2):131-42.
Risks versus benefits of testosterone therapy in elderly men.
Click here to access the PubMed abstract of this article.

Patients using testosterone should seek medical attention immediately if symptoms of a heart attack or stroke are present, such as:

  • Chest pain
  • Shortness of breath or trouble breathing
  • Weakness in one part or one side of the body
  • Slurred speech

Goals of Testosterone Replacement Therapy in Adult Hypogonadal Men (age 50 or older)

  • Improvement in psychological well-being and mood
  • Improvement in erectile dysfunction
  • Improvement in libido
  • Increased muscle mass
  • Increased strength and stature
  • Preservation of bone mass

A man may be considered hypogonadal at any age if total testosterone is less than 200 ng/dl, or bioavailable testosterone is less than 60 ng/dl. Basaria and Dobs of Johns Hopkins University recommend that elderly men with symptoms of hypogonadism and a total testosterone level < 300 ng/dl should be started on hormone replacement.

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