what kind of compounding do pharmacists engage in?

[defiancy]

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One aspect of pharmacy that always fascinated me was compounding. I heard though the practice of compounding is nearly dead since the emergence of huge pharmaceutical companies, but to some extent there is some compounding done by pharmacists. In fact, I heard there's a compounding pharmacist who just specializes in creating their custom drugs for patients.

My question for you pharmacists:

• What kind of compounding was engaged in the past versus what kind of drugs are compounded today?

• Do compounding pharmacists compound more advanced drugs compared to regular community pharmacists?
• When you do engage in compounding, do you guys measure in moles, molarity all that chemistry stuff or just simple weights?
• What goes on in your head when someone says I need a medicine for _____. How do you know exactly what to put in the mortar /pestle?
• Do you guys think about how chemicals rearrange themselves and how they interact as you make them?

Finally, an apology for the list of questions, but I am curious

 

[PharmDstudent]

They do topical stuff like lotions and ointments as well as IV fluids.

 

[Aznfarmerboi]

It is good that you are interested in compounding and since most major retail companies dont do it, it is a highly profitable niche. I dont have a lot of experience in compounding pharmacy but this is what i know.

What kind of compounding was engaged in the past versus what kind of drugs are compounded today?
In the past (not too sure and assuming since I am still young), a pharmacist might convert one dosage form to another (table to capsule or suspension). Currently, it depends on where you compound. In the hospital, your main job will be compounding IVs. In retail, it may be doing topicals or adding flavoring for kids.

Do compounding pharmacists compound more advanced drugs compared to regular community pharmacists? I am going to answer No because I have no clue what do you mean by more advanced drugs? Do you mean nuclear speciality? Chemo?

When you do engage in compounding, do you guys measure in moles, molarity all that chemistry stuff or just simple weights? Nowadays, compounding in the US is mostly based on micrograms, milligrams, grams, CC/ML. Chances are good that you will not stumble upon moles, molarity, and all that "chemistry stuff" unless you have to do MEQ.

What goes on in your head when someone says I need a medicine for _____. How do you know exactly what to put in the mortar /pestle? It comes with experience, but for a pharmacist who is new in compounding can always look up the ingredients in various resources. In terms of motar/pestle, that comes with training in your compounding class. Depending on the compound and what you do with it, you will know what equipment to use. Furthermore, there are a few known eutectics and voltile compounds that you will have to remember and "just know it".

Do you guys think about how chemicals rearrange themselves and how they interact as you make them? Most chemicals dont really "rearrange" themselves. We do think about how they interact with each other such as acid/base, any reaction with other ingredients (tetracycline with dicalcium phosphate), melting point, solubility, etc.

 

[DrugDealer]

The compounding pharmacies also make a lot of suppositories.

There are also some meds that don't come as a liquid, so in retail you may convert them to a solution or suspension. Opening up the capsules or grinding up the tablets, then dissolving them in whatever.

There's also a children's pharmacy I've seen in NY (West Village-ish) that looks pretty cool (and I don't even like kids!)....I always wonder if they make lollipops.

 

[dumbguy]

i volunteered at a compounding pharmacy 2 years ago and they did compounding on hormones and any prescription that requires compounding they do. I work for a retail pharmacy now and any prescription that requires compounding, we send our customers to a compounding pharmacy.

 

[dumbguy]

The compounding pharmacies also make a lot of suppositories.

There are also some meds that don't come as a liquid, so in retail you may convert them to a solution or suspension. Opening up the capsules or grinding up the tablets, then dissolving them in whatever.

There's also a children's pharmacy I've seen in NY (West Village-ish) that looks pretty cool (and I don't even like kids!)....I always wonder if they make lollipops.

oh i forgot, they make lollipops out of medication and flavor them so kids will take them!

 

[amritchiluwalia]

how much money do these compounding pharmacists make??

 

[PharmDstudent]

how much money do these compounding pharmacists make??

They usually make less than retail pharmacists. One of the pharmacists I know took a pay cut to work for an independent compounding pharmacy. I heard the cut in pay was fairly significant.

 

[Aznfarmerboi]

They usually make less than retail pharmacists. One of the pharmacists I know took a pay cut to work for an independent compounding pharmacy. I heard the cut in pay was fairly significant.

Actually, they dont "usually" make less than retail pharmacists. The situation really depends on where the pharmacist practice. In reality, a pharmacist with real compounding knowledge makes about the same if not more than a retail pharmacist. Of course, there is no true statistics out there but the money you make once again depends on where you practice and your niche.

 

[PharmDstudent]

Actually, they dont "usually" make less than retail pharmacists. The situation really depends on where the pharmacist practice. In reality, a pharmacist with real compounding knowledge makes about the same if not more than a retail pharmacist. Of course, there is no true statistics out there but the money you make once again depends on where you practice and your niche.

Good point. I shouldn't have made a generalization like that.

 

[ZpackSux]

I used to compound TPNs like a fool. About 50 a day as an intern.

And I didn't get paid very much. But I got really proficient at mixing IVs.

 

[PharmDstudent]

I used to compound TPNs like a fool. About 50 a day as an intern.
And I didn't get paid very much. But I got really proficient at mixing IVs.

I'm really proficient at typing although I've gotten better lately. Some of the customers remark about my typing skills, happened yesterday actually. The typing class I toke in sixth grade was worth it!

 

[Old Timer]

In the past pharmacists made:

1) Powders, both standard and effervescent.
2) Capsules of all types (Obecalp, Sodium Fluoride, Various Antacid/Antimuscarinic GI cocktails.
3) Topical creams, ointments and lotions
4) Suppositories, both vaginal and rectal.

Nowadays, hospital pharmacists do more compounding than most retail pharmacies. Except for compounding pharmacies, most retail pharmacies make:
Progesterone Suppositories
Topical creams/ointments/lotions
Many oral liquid medications for children, especially if you are near a childrens hospital.

 

[tussionex]

i make all manner of IV preparations...TPN, antibiotics, plain old fluids, PCA's, epidurals, IVIG, you name it

retail compounding pharmacies also make veterinary products. a place i worked at used to make stuff for a horse farm.

 

[defiancy]

When you guys compound IVs and other medications what do you guys do....mind if you tell me the general steps? I would think it would be awesome if I can wear goggles and gloves while mixing the chemicals in, but I'm not sure if that's the case after reading these answers. Do you find compounding very creative? I don't make mind making a disguised lollipop, but mixing dangerous chemicals into useful forms seems exciting for me

 

[sdn1977]

You are getting a lot of mixed information here...

In hospitals, you might do compounding, but mostly your techs will compound (hopefully!). Altho, I've done my fair share of tpns, tpas, chemos & any number of antiobiotics!

You wear masks, goggles, protective apparel when mixing chemotherapy drugs. You also might get asked to do periodic urine samples to detect for mutations. There are a few studies which are following these over time for compounders. (Some of these used to be compounded by nurses at a desk in a doctors office!!!).

For outpatient settings, it is becoming increasingly onerous to do compounding. In fact, there is significant political & professional pressure to prevent extemporaneous compounding in view of the recent (the last few years) of compounding mistakes which have resulted not just in morbidity, but mortality.

So far, these have all been forestalled by the professional group which does compounding, which you have to be a member of to even purchase the drugs to compound with. Not just any pharmacist can purchase the raw chemicals.

Currently, you must go through training, know your state's laws & federal laws which dictate the compounding statues & limitations with respect to what & what situations you can compound under.

This is not a venture to be undertaken lightly. I personally know of a pharmacist who compounded a steroid injection for use by orthopedic surgeons. He had compounded it for years & years without problems.

On one occurrence, the compounding was done, as it was frequently, by a technician & checked by the second pharmacist - not himself as the owner - he was off the premises.

Unfortunately, three patients suffered infections which were directly related to the injection material - one patient died. All participants were sued. The technician lost her license and paid a fine. The supervising pharmacist was put on probation, fined & supervised for 3 years. The owner, who was not on the premises at the time, had his licensed put on probation for 3 years, fined & ultimately committed suicide by using fentanyl patches.

A very sad story indeed. Do not go into compounding lightly & absolutely do NOT go into compounding anything which is currently commercially available. There is NO justification for this! Also - there are many case reports of pharmacists who have had their licenses suspended by compounding for physicians or patients who are out of state. Do NOT do this - you are now considered a manufacturer & are held to entirely different statutes.

Be careful & cautious!

 

[acetyl]

Unfortunately, three patients suffered infections which were directly related to the injection material - one patient died. All participants were sued. The technician lost her license and paid a fine. The supervising pharmacist was put on probation, fined & supervised for 3 years. The owner, who was not on the premises at the time, had his licensed put on probation for 3 years, fined & ultimately committed suicide by using fentanyl patches.

Wow.

 

[defiancy]

That is pretty sad and I do realize those risks exist for a compounder. The story is very unfortunate.





I'm not sure if this was fully answered... for an ordinary compounding pharmacy what do they tend to compound there...just suppositories? Does any of their work involve gloves/goggles at all?

 

[Aznfarmerboi]

You are getting a lot of mixed information here...

In hospitals, you might do compounding, but mostly your techs will compound (hopefully!). Altho, I've done my fair share of tpns, tpas, chemos & any number of antiobiotics!

You wear masks, goggles, protective apparel when mixing chemotherapy drugs. You also might get asked to do periodic urine samples to detect for mutations. There are a few studies which are following these over time for compounders. (Some of these used to be compounded by nurses at a desk in a doctors office!!!).

For outpatient settings, it is becoming increasingly onerous to do compounding. In fact, there is significant political & professional pressure to prevent extemporaneous compounding in view of the recent (the last few years) of compounding mistakes which have resulted not just in morbidity, but mortality.

So far, these have all been forestalled by the professional group which does compounding, which you have to be a member of to even purchase the drugs to compound with. Not just any pharmacist can purchase the raw chemicals.

Currently, you must go through training, know your state's laws & federal laws which dictate the compounding statues & limitations with respect to what & what situations you can compound under.

This is not a venture to be undertaken lightly. I personally know of a pharmacist who compounded a steroid injection for use by orthopedic surgeons. He had compounded it for years & years without problems.

On one occurrence, the compounding was done, as it was frequently, by a technician & checked by the second pharmacist - not himself as the owner - he was off the premises.

Unfortunately, three patients suffered infections which were directly related to the injection material - one patient died. All participants were sued. The technician lost her license and paid a fine. The supervising pharmacist was put on probation, fined & supervised for 3 years. The owner, who was not on the premises at the time, had his licensed put on probation for 3 years, fined & ultimately committed suicide by using fentanyl patches.

A very sad story indeed. Do not go into compounding lightly & absolutely do NOT go into compounding anything which is currently commercially available. There is NO justification for this! Also - there are many case reports of pharmacists who have had their licenses suspended by compounding for physicians or patients who are out of state. Do NOT do this - you are now considered a manufacturer & are held to entirely different statutes.

Be careful & cautious!

I heard about the story too, but errors happen everywhere including hospital pharmacy, retail pharmacy, nuclear pharmacy, etc. Anything dealing with drugs should be taken seriously especially if you are injecting it into the blood stream.

Deficncy, the benefits of a compounding pharmacists in either case is still pretty high. If you do get accepted into pharmacy school, chances are very few if any of your classmates will be interested in this niche. A lot of the compounding pharmacists out there (imo and i am sterotyping, are usually bachelors) are going to be retiring soon and not a lot of pharmacists are stepping up to take their place. A lot of money can be made in this field.

About manufactuering, that is true as also compounding more than 5 percent in advance for a patient versus what you have in stock and so on etc etc. I am sure you will learn this in your pharmacy law class. Its funny how the FDA said that they would only be using this rule against pharmacists who are disguising manufacturing as compounding, but have attacked pharmacists who are actually providing a valuable service to patients living near a border. However, the rules are still constantly changing especially concerning manufacturing and a lot of rules are going to be tested in the years to come definitely.

 

[defiancy]

It would be helpful if I knew all the things that a compounding pharmacist can compound. As I said before, does any compounding pharmacist outside the hospital scene get involved with the "heavy-duty" stuff with goggles/gloves? So far it's been explained they make suppositories, ointments, creams....but what else? I'm only eager to know what they are capable of since I never had an interaction with a compounding pharmacist

 

[cycloketocaine]

It would be helpful if I knew all the things that a compounding pharmacist can compound. As I said before, does any compounding pharmacist outside the hospital scene get involved with the "heavy-duty" stuff with goggles/gloves? So far it's been explained they make suppositories, ointments, creams....but what else? I'm only eager to know what they are capable of since I never had an interaction with a compounding pharmacist

At my pharmacy (retail indy) we don't use the goggles and gloves, because we have a huge hood that makes it so we don't have to. We use it to make IV's and stuff

 

[ZpackSux]

At my pharmacy (retail indy) we don't use the goggles and gloves, because we have a huge hood that makes it so we don't have to. We use it to make IV's and stuff

In Oklahoma, you may call it the huge hood, but everywhere in the US we call it Laminar or Vertical Flow Hood with HEPA filter.

 

[sdn1977]

It would be helpful if I knew all the things that a compounding pharmacist can compound. As I said before, does any compounding pharmacist outside the hospital scene get involved with the "heavy-duty" stuff with goggles/gloves? So far it's been explained they make suppositories, ointments, creams....but what else? I'm only eager to know what they are capable of since I never had an interaction with a compounding pharmacist

Generally - no. Protective equipment is only used for those drugs which can cause harm to the compounder - antineoplastics, radioactive substances. There are a very few of these in an outpt setting - less than 20 I'd guess. Since these products are given either in a hospital or outpt setting associated with a hospital & the physical requirements of the facility are expensive to build....its normally done in a hospital - at least in my area.

We are capable of doing most anything. We just make a choice of our practice setting which then dictates what we do. If you want to compound, you'll need to get specialty training & jump thru as yet undetermined hoops as someone else said are constantly changing. Depending on who wins the political war which is going on now, pharmacists will still be allowed to compound these unusual items or they'll be entirely banned from it.

Why would it be helpful to know ALL the products which can be compounded? What I knew was compounded in 1980 is not being compounded now & that will change again in the years ahead. Go observe a hospital main pharmacy & you'll see lots of compounding (IVs & if at the VA - huge vats of nonsensical creams).

 

[dgroulx]

It would be helpful if I knew all the things that a compounding pharmacist can compound. As I said before, does any compounding pharmacist outside the hospital scene get involved with the "heavy-duty" stuff with goggles/gloves? So far it's been explained they make suppositories, ointments, creams....but what else? I'm only eager to know what they are capable of since I never had an interaction with a compounding pharmacist

We make mainly oral stuff, like prilosec + bicarb, nystatin + maalox + lidocain, and occasional creams. Any odd compounds that are made of ingredients that we don't normally have on hand are referred to a compounding pharmacy.

 

[cycloketocaine]

In Oklahoma, you may call it the huge hood, but everywhere in the US we call it Laminar or Vertical Flow Hood with HEPA filter.

I hate you. 😡

 

[All4MyDaughter]

At our VA we compound quite a bit -

Outpatient pharmacy
Lots of Magic Mouthwash for patients on chemo

Various different creams and ointments for derm conditions - we have a wide variety of pathologies and make many different combos. In fact, we dispense so much of this stuff that we make it ahead of time and store it in bar coded jars, ready to dispense when we get an order for it.

Can't think of anything else right now. I'm assigned to the clinical service so I haven't worked outpatient lately.

Inpatient pharmacy
IVs, chemo, TPN
Same creams as outpatient, if a patient is admitted and is on one.

 

[bananaface]

Closed door pharmacies (not open to the public) are often overlooked. There are places that serve as suppliers for nursing homes and other care facilities that are set up to supply things like customized IV admixtures, in addition to the commercially available products. They are likely to also provide non-complicated creams and oral suspensions and solutions, but not to bother with more involved compounds like customized capsules, troches, lollipops, and suppositories. What they will compound is often similar to what a hospital pharmacy will compound.

Some open door compounding pharmacies have facilities for compounding sterile products. In addition to IVs, eye drops are another product that can be produced if one has the correct facilities, materials, and skills. In some areas, non-commercially available eye drops are extremely popular with veterinarians. The compounding pharmacists I have spoken to typically say about 1/4 of their business is referrals from local Vets.

 

[ZpackSux]

I hate you. 😡

Oh...you do not.😍

 

[ZpackSux]

I didn't feel like responding to this thread because it's not of my interest.

But here we go.

The compounding can mean many different things in the pharmacy both in and outpatient. It could be as simple as mixing 2 different oral solutions, or little more complex as sterile IV nutrition prepared in a sterile environment.

But the latest fad in compounding boom occured due to manufacturing problems affecting injectible drugs faced by many different pharmaceutical companies about 7 to 8 years ago. Some problems rose from violations of FDA's good manufacturing practice whereas other problems came from lack of raw material...or hurricane in Peurto Rico where plants had to shut down.

So, to capitalize on the void, many independent retail pharmacies setup sterile compounding pharmacy to manufacture unavailable injections from non sterile raw product. And they gouged hospital pharmacies.

Remember, sterility of an oral preparation is not a big issue. Not many things can live through our GI tract. But sterility of injectible drugs is of an utmost importance since introduction of contamination through intravenous route can be fatal. And because this was not an industry heavily regulated, soon we started see problems as SDN1977 mentioned.

Then came the USP797. Well intentioned regulation to make sure sterile compounding is done properly. But it is a whole another topic for another day.

But I can tell you the sterile compouding of injectibles by your local pharmacies are waning.

 

[sdn1977]

I didn't feel like responding to this thread because it's not of my interest.

But here we go.

The compounding can mean many different things in the pharmacy both in and outpatient. It could be as simple as mixing 2 different oral solutions, or little more complex as sterile IV nutrition prepared in a sterile environment.

But the latest fad in compounding boom occured due to manufacturing problems affecting injectible drugs faced by many different pharmaceutical companies about 7 to 8 years ago. Some problems rose from violations of FDA's good manufacturing practice whereas other problems came from lack of raw material...or hurricane in Peurto Rico where plants had to shut down.

So, to capitalize on the void, many independent retail pharmacies setup sterile compounding pharmacy to manufacture unavailable injections from non sterile raw product. And they gouged hospital pharmacies.

Remember, sterility of an oral preparation is not a big issue. Not many things can live through our GI tract. But sterility of injectible drugs is of an utmost importance since introduction of contamination through intravenous route can be fatal. And because this was not an industry heavily regulated, soon we started see problems as SDN1977 mentioned.

Then came the USP797. Well intentioned regulation to make sure sterile compounding is done properly. But it is a whole another topic for another day.

But I can tell you the sterile compouding of injectibles by your local pharmacies are waning.

Sterile compounding of ANYTHING - injectables, eyedrops, IVs...all of it will ultimately require JCAHO accreditation (doesn't matter if you're a retail, closed door, inpt - all of them) & specialty credentials. JCAHO accreditation is a royal pain in the *ss (would you not agree Zpak) and they are very, very strict with regard to sterile products.

Those products which you can't get thru your wholesaler are usually available under orphan drug status. Not only that, there are fewer & fewer prescribers who are taught this crazy stuff we used to "compound" (there is absolutely NO purpose in a coal tar anything!).

As for vets - they have their own wholesalers of vet products. My experience with vets is they use retail pharmacies to try to get better pricing than what is available thru their wholesalers. You gotta be careful there too - they are allowed to have pharmacy techs "dispense" out of a vets office. So, whatever you might have compounded could later have been "dispensed" and not by the prescriber him/herself. I could tell you vet stories too.

Zpak - are you old enough to remember the Abbott contamination of the 80's? It nearly put the company out of business....They had multiple contaminated products & their amino acids were one of them.

 

[sdn1977]

At our VA we compound quite a bit -

Outpatient pharmacy
Lots of Magic Mouthwash for patients on chemo

Various different creams and ointments for derm conditions - we have a wide variety of pathologies and make many different combos. In fact, we dispense so much of this stuff that we make it ahead of time and store it in bar coded jars, ready to dispense when we get an order for it.

Can't think of anything else right now. I'm assigned to the clinical service so I haven't worked outpatient lately.

Inpatient pharmacy
IVs, chemo, TPN
Same creams as outpatient, if a patient is admitted and is on one.

See - nothing's changed in 35 years. I was an intern at one of the largest VA's on the west coast (known for where Legionnaie's Disease was finally isolated) - and we made tubs and tubs of creams & ointments. Ugh!

See what these poor vets have to deal with??? This is not how dermatology is practiced in the private sector. Most of that stuff is available commercially & if its not - its not because its useless. There is no more extensive pathology in the VA than in the private sector - just more goo.

You get that same vet, retired & on TriCare who can see a private practice dermatologist & the tx is significantly different & the pt is very, very grateful.

 

[ZpackSux]

Sterile compounding of ANYTHING - injectables, eyedrops, IVs...all of it will ultimately require JCAHO accreditation (doesn't matter if you're a retail, closed door, inpt - all of them) & specialty credentials. JCAHO accreditation is a royal pain in the *ss (would you not agree Zpak) and they are very, very strict with regard to sterile products.

Those products which you can't get thru your wholesaler are usually available under orphan drug status. Not only that, there are fewer & fewer prescribers who are taught this crazy stuff we used to "compound" (there is absolutely NO purpose in a coal tar anything!).

As for vets - they have their own wholesalers of vet products. My experience with vets is they use retail pharmacies to try to get better pricing than what is available thru their wholesalers. You gotta be careful there too - they are allowed to have pharmacy techs "dispense" out of a vets office. So, whatever you might have compounded could later have been "dispensed" and not by the prescriber him/herself. I could tell you vet stories too.

Zpak - are you old enough to remember the Abbott contamination of the 80's? It nearly put the company out of business....They had multiple contaminated products & their amino acids were one of them.

The Joint Commission has lost their mind long ago. And when that happened with Abbott now called Hospira, I believe I was racing BMX bicycles down in New Orleans!

 

[mvilland]

COMPOUNDING IS ALIVE AND WELL IN THE SOUTH!👍

 

[sdn1977]

COMPOUNDING IS ALIVE AND WELL IN THE SOUTH!👍

You're right! I just read about four Florida pharmacists who pled guilty on felony charges related to rx compounding.

Grrreeeaaaatttt!