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When Ordering Compounded Medications: What Pharmacists Want You To Know

Acknowledgments: Credit to Dr. Natasha Thompson, Wickliffe Veterinary Compounding Pharmacist, University of Kentucky Professor, PharmD, RPh, Published Author, Kentucky Pharmacist Association Presenter, for her contribution and collaboration on this article.

Veterinarians often encounter cases where commercially available medications are not suitable for their patients due to various reasons including but not limited to: limited dosage forms, flavor preferences, or the unavailability of specific drugs due to backorder or discontinued products. Additionally, the strength of medication needed for treatment may not be commercially available. In such situations, compounded medications offer a valuable solution. Compounding pharmacies can create customized medications tailored to the unique needs of individual animals. However, for a successful compounded medication order, veterinarians need to provide certain crucial information.

The veterinary compounding medication process is analogous to ordering human compounding medications. Pharmacists provide a full “DUR” (drug utilization review) upon receipt of every prescription. A DUR is “an ongoing, systematic process designed to maintain the appropriate and effective use of medications. (1) It involves a comprehensive review of a patient’s medication and health history before, during, and after dispensing in order to attempt to achieve appropriate therapeutic decision-making and positive patient outcomes. Pharmacists participating in DUR programs can directly improve the quality of care for patients, individually and as populations, by striving to prevent the use of unnecessary or inappropriate drug therapy, prevent adverse drug reactions, and improve overall drug effectiveness.”

To ensure a DUR is all-encompassing, it is imperative that pharmacists have all the necessary information about the veterinary patient as well as the medication prescribed to facilitate the process to ensure optimal therapeutic patient care.

What information is needed when a veterinarian orders a compounded medication to ensure the safety and efficacy of the treatment?

Patient Information

Before compounding a medication, veterinarians must provide comprehensive patient details. This includes:

Animal’s Name: Give the animal’s name as well as the owner’s first AND last name. The owner’s address and phone number are also needed to create a new patient profile.

Species: Specify the animal species, whether a dog, cat, horse, exotic, or other animal.

Also, something to note for food-producing animals (sheep, rabbits, deer, goats, cows, etc.), a veterinarian will have to send in a “Veterinary Letter of Intent” to indicate that the animal that is being treated with medication will not be consumed for meat and/or their milk will not be used.

Breed and Age: Different breeds and age groups may have varying intolerances and sensitivities to certain medications. The age and breed of an animal can affect the absorption, elimination, and excretion of medications. Pharmacists take both into account when calculating that the dose is correct and not an overdose/underdose. In addition, some medications are not approved for use in animals <1 year or in pregnant and nursing female animals.

Weight: Accurate weight information is crucial for calculating the appropriate dosage.

Medical History: Provide information about the patient’s medical history, including any allergies, intolerances, medication history, diagnoses, or previous adverse reactions to medications. It is essential to note what medications the animal is currently on to check for drug interactions as well as disease states, comorbidities, or other underlying factors that could affect the absorption or elimination of a drug. If the animal is pregnant or nursing, it is vital to consider the effect of the prescribed drug on the fetus.

Diagnosis: Clearly state the medical condition or diagnosis for which the medication is required.

Medication and Strength

Veterinarians should specify the exact medication required and its desired concentration or strength. This includes:

Drug Name: Clearly state the name of the active ingredient(s) needed – either brand or generic.

Concentration: Specify the concentration of the active ingredient in the final product (e.g., milligrams per milliliter). *It is important to ensure the per ml is correct for suspension, injectables, paste, and solutions. Example: pergolide 1mg/ml versus 1mg/5ml.

Dosage Form: Indicate the preferred dosage form (e.g., tablets, capsules, liquid, cream, gel, ointment powder, tablet, oral disintegrating tablets, chewable, injectables, solution, suspension, paste, ointment, gel, transdermal).

Flavor and Palatability

Some animals may be selective when it comes to taking medication. Veterinarians should provide information about flavor preferences or any known allergies to specific flavors. This ensures that the compounded drug is effective and palatable for the patient, thereby optimizing therapeutic care and response.

Dosage Instructions

Clearly define the dosing instructions, including:

Dosage: State the quantity of medication to be administered (e.g., 5 mls, one tablet, 1 scoop, etc).

Route Of Administration: po (oral), IM, IV, subcutaneous, rectally, vaginally, intrauterine, topically, etc.

Frequency: Specify how often the medication should be given (e.g., once daily, every 12 hours).

Dosage Instructions: Be specific. Example: Give one scoop orally twice daily (every 12 hours), inject 5 mls IM every week, administer 1 ml orally once daily.

Duration: Indicate the duration of the treatment (e.g., 7 days, until symptoms improve, etc.). This is especially important for antibiotics because many pet owners will stop antibiotics for their pets prematurely (once symptoms improve), thereby not finishing the full course of treatment which can ultimately lead to antibiotic resistance.

Special Instructions: Include any special administration instructions, such as to take with food or water or avoid administering certain medications concurrently.

Drug interactions: It is imperative to provide a complete medication history of the patient to make sure there are no drug interactions. Also, one should note if the medication needs to be taken with water, 30 minutes before or after food (for absorption purposes), etc. Storage considerations (at room temperature- especially important for farm animals if medication is stored in a barn during summer or winter months- during extreme heat or cold), not in direct sunlight, shake well (for suspensions/ some injectables that can separate), etc.

Prescribing Veterinarian Name: Specify if there is more than ONE vet at the clinic. Also, make sure license numbers and DEA numbers are up to date and on hand to enter into the system if need be.

Refills: Maintenance medications can be requested “as needed” (prn) refills for simplicity’s sake to make ordering refills in the future easier. Or, if just a one-time fill, zero refills can be indicated. Controlled substance prescriptions (stanozolol, tramadol, phenobarbital, etc.) can be refilled for up to 6 months, but not to exceed 5 total refills (whichever comes first).

Day Supply: Make sure when giving the dosing directions that the drug will not exceed the BUD (beyond use date).

Herd Dosing: Example: if a farm vet is administering a drug to a herd of cows, the compounding pharmacy will need all the specific animal information (for each animal) in that herd.

Reason For Compounding: Be prepared to indicate why the veterinarian needs a compounded medication versus ordering via a manufacturer. Why is a commercial product not being used? Acceptable examples include drug shortage, back-order, commercially available product discontinued, modified release, inactive ingredient sensitivity/intolerance/allergy, inactive ingredient toxic to species, concentration adjustment necessary, alternative administration route, patient noncompliance, or alcohol-free.

Office Use: The FDA has provided an office use approved list for compounding medications. Designated Office use products Do not require patient specific descriptors.

Flavor: What flavor would the patient prefer or tolerate best to increase patient medication acceptance? Companion animals (dogs, cats) often choose fish, beef, tuna, chicken, or peanut butter. Equine patients often prefer alfalfa, peppermint, molasses, apple, or vanilla.

Any Essential Laboratory Findings: Indicate any essential laboratory findings including but not limited to; CBC, platelet, serum chemistry profiles, etc., that may interfere with dosing.

Indication/Disease State: The pharmacist needs to know the patient’s diagnosis and other comorbidities/underlying disease states to ensure an optimal dosing regimen and to account for elimination, pharmacokinetic, and pharmacodynamic contributors. Some drugs have multiple indications, so the dose can vary based on what disease state is being treated.