Compounding: Individual Solutions to Medication Challenges

Pharmacist Zoe Stefanadis, preparing an individually tailored medicine for one of her clients.


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“I could argue,” observes Zoe Stefanadis, founder and owner of Chapel Hill Compounding pharmacy, “that prescription drugs pose one of the most significant challenges in medical care.

“Don’t misunderstand me,” she adds. “Advances in pharmaceutical treatments—from penicillin on—have been enormously beneficial. They have provided cures for diseases that were once thought incurable and help manage health conditions that might otherwise be debilitating or even life threatening.

“However, the problem with prescription medications is that they are—unavoidably—designed for the ‘average’ patient. And when it comes to medication, one size does not fit all. This is why pharmaceutical compounding is so important.”

“We’re all different,” explains Ms. Stefanadis. “Each one of us metabolizes food and medications differently, and that process is affected by all the things that make us unique—our genes, age, health history, lifestyle. These factors not only influence the effectiveness of the active ingredient in a prescription drug, but how one’s body absorbs and uses the medication. The goal always is to find the best way to deliver a medication, so that it has maximum benefit, with minimum risk, for that particular patient.

“Compounding allows us to meet that goal,” she says, “by customizing dosages and delivery mechanisms, balancing medications, avoiding adverse effects, and even addressing the unique needs of animals or children.”

Customizing Dosages

“A patient I’ll call Susan is a classic example of the challenge of finding the right—meaning the ‘effective’—dose of a medication,” says Ms. Stefanadis. “Susan was suffering from hypothyroidism, but her unique needs didn’t match commercially available thyroid medication dosages. Since no one pill provided the consistent dose needed to control her hypothyroidism, her ‘prescription’ involved five different strengths of thyroid medication, and instructions to take three pills on one day, two on another, and one on the next. It was a nightmare! And, of course, it really didn’t work.”

Working with Susan’s doctor, Ms. Stefanadis compounded a specific dose that could be taken once daily—an option that wasn’t commercially available. “It was very fulfilling to be able to compound that dose for her, and to have a great outcome,” she says. “Susan referred to it as a life-saver, both in helping her regain her quality of life and in making it simple for her to maintain it.”

Sometimes, notes Ms. Stefanadis, the challenge of finding the right dosage is related to changing or stopping medications. “For example, physicians commonly prescribe SSRIs to treat depression or anxiety for a short period. But abruptly stopping these medications can trigger extreme withdrawal symptoms.

“In such cases, compounding plays a vital role in helping patients safely taper off medications. For example, we can reduce dosages by as little as two percent every two weeks—something you can’t do by cutting up a pill. In this way, the body will not even notice that the drug is no longer in the system, and there’s no withdrawal crisis.”

Such delicate adjustments are particularly useful in finding the optimum dosages for certain medications. “We frequently help patients taking low-dose naltrexone (LDN),” notes Ms. Stefanadis. “LDN is an anti-inflammatory drug that is extremely effective in treating a wide range of chronic health problems, including pain. But ‘one size’ most definitely does not fit all, and it’s important to gradually increase dosages to find the most effective level for the particular patient,” she explains.

“I’ll typically start patients on doses as low as .5mg, with the goal of getting them to a therapeutic dosage safely. The standard dose is 4.5mg, but some people do well at 3mg and some people might actually need to go up higher.”

Minimizing Risk of Adverse Effects

Just as important as the dosage, explains Ms. Stefanadis, is how a medicine is delivered. “The more common ‘delivery’ mechanism,” she points out, “is to take a pill. But swallowing a pill ‘delivers’ the medication to your whole body via your digestive system. And some medications—which may be designed to address a specific problem, such as arthritic joint pain—may have an adverse impact on the digestive system.

“And that’s just one aspect of what we call the ‘delivery’ system,” she explains. “Besides the active ingredient, medicines include fillers and additives that are designed to make the medicine easer to absorb but may also produce adverse effects.”

Adverse effects are a common problem encountered with most prescription medications, notes Ms. Stefanadis. “I prefer to use the term adverse effects rather than side effects,” she says, “because any medication will have side effects—responses unrelated to the condition being treated. Some—such as drowsiness when taking an antihistamine—are benign. But what’s of concern is an adverse effect—such as when a medication produces an allergic response. A simple example is a patient with alpha-gal—an allergy to red meat. For that patient, any medicine in a gelatin capsule could be a problem because gelatin is derived from animal protein. We can avoid that problem by using vegetable-based capsules.”

Compounding is especially useful in targeting medications. “As I mentioned,” says Ms. Stefanadis, “medications taken orally move through the digestive system, which can be especially problematic with many pain medications.

“That is why I love transdermal pain medication delivery. Topical, transdermal treatments—applied with a gel—avoid the harmful side effects to the stomach, kidneys, and liver and minimize or eliminate all effects on the central nervous system. And, critically important, we consistently achieve an improved therapeutic outcome because we’re going directly to the source of the pain.”

Supporting Special Populations

Compounded medications are invaluable for those with special needs—and that includes our pets. “Have you ever tried to give a cat a pill?” asks Ms. Stefanadis. “That’s a classic problem—and one where compounding really makes a difference. A compounded thyroid medication for cats can be rubbed inside the cat’s ear, and although it’s applied locally, it gets absorbed systemically.”

Other medications—such as some medications for dogs—may simply not be available in correct dosages commercially. “For example,” says Ms. Stefanadis, “you cannot transcribe a human dose for a dog dose. Despite their lower weight, dogs actually need a higher dose of medications because they have a larger vascular system than humans.” Compounding provides a solution.

“Sometimes,” says Ms. Stefanadis, “the special need is just a medication’s tolerability. For children, we can add flavoring or reduce particle size to make medicines less grainy. And we can concentrate a dose, which means that the amount a child has to take at one time is smaller and easier to swallow.

“Thanks to many recent innovations,” says Ms. Stefanadis, “compounding is able to provide an individualized solution to nearly all medication challenges: bio-identical hormone replacement therapy, veterinary medications, hospice medications, pediatric formulations, dental, dermatologic, chronic pain medications, medications for infertility, wound therapy, sports medicine—and much more.”