The Use Transdermals in Palliative Care 
Transdermal gels allow patients medication to be delivered by applying them to the skin. This prevents the pain and discomfort plus indignity for rolling a patient over to give medications rectally. It allows a healing touch by the care giver by applying the medication to the skin.
Palliative care is a type of therapy that a patient has never faced before. It is important for care givers and loved ones to assure the patient that their needs will be met. If the patient is suffering from constipation due to their high dose pain medications, laxatives might be inadequate to bring relief. Other medications (e.g. dextromethropan) can be added to the narcotic dose. This allows the narcotic dosage to be reduced, relieving the constipation while still maintaining the pain relief. With bone metastasis, oral narcotics are not effective for bone pain. The non-steroidal anti-inflammatory drugs (NSAIDs) (e.g. Ibuprofen or Ketoprofen) are the drugs of choice. However, in many cases they cannot be given orally due to stomach upset, nausea and vomiting. The transdermal gels (see below) allow these medications to be delivered through the skin without the gastric side effects.

The transdermal gels are the workhorses for compounding pharmacists in palliative care. They can be a vehicle for delivery of the patient’s daily medications. Transdermals are used to deliver anti-nausea medications (e.g. promethazine), ABH, ABHR and steroids (e.g. dexamethasone). Anti-anxiety medications can also be delivered transdermally. Below is a link showing various medications and their actions that can be combine in a transdermal gel for pain. This allows the physician to create the most effective product for their patient’s pain. The transdermals can be applied locally and along the afferent nerves (e.g. knee pain, the gel is applied to the knee and along the lateral horns where the afferent nerves enter the spine). These custom gels give the physician a tool to control the patient’s pain, while reducing or minimizing the patient’s need for systemic medications and their side effects.

If you are a pain patient or a patient’s care giver, you might want to print the table off and discuss the use of transdermal gels with your physician.

The link below is a short Power Point presentation of some factors that are involved in providing a quality transdermal preparation.

The following abstract from Pubmed reinforces the importance of the ointment mill and particle size in the preparation of quality transdermal gels.

Int J Pharm. 2008 Jun 5;357(1-2):295-304. Epub 2008 Feb 3.
Lipid nanoparticles for prolonged topical delivery: an in vitro and in vivo investigation.
Puglia C, Blasi P, Rizza L, Schoubben A, Bonina F, Rossi C, Ricci M.
Department of Pharmaceutical Sciences, School of Pharmacy, University of Catania, viale A. Doria 6, 95125 Catania, Italy.

Dermal therapy is still a challenge due to the difficulties in controlling the active pharmaceutical ingredient (API) fate within the skin. Recently, lipid nanoparticles have shown a great potential as vehicle for topical administration of active substances, principally owing to the possible targeting effect and controlled release in different skin strata. Ketoprofen and naproxen loaded lipid nanoparticles were prepared, using hot high pressure homogenization and ultrasonication techniques, and characterized by means of photo correlation spectroscopy and differential scanning calorimetry. Nanoparticle behavior on human skin was assessed, in vitro, to determine drug percutaneous absorption (Franz cell method) and, in vivo, to establish the active localization (tape-stripping technique) and the controlled release abilities (UVB-induced erythema model). Results demonstrated that the particles were able to reduce drug penetration increasing, simultaneously, the permeation and the accumulation in the horny layer. A prolonged anti-inflammatory effect was observed in the case of drug loaded nanoparticles with respect to the drug solution. Direct as well as indirect evidences corroborate the early reports on the usefulness of lipid nanoparticles as carriers for topical administration, stimulating new and deeper investigations in the field.

PMID: 18343059 [PubMed - indexed for MEDLINE]
The 90 second video below demonstrates the importance of one piece of equipment in the outcome of the final medication.