Going Toe-to-Toe with Pain: Compounding Topical Medications for Podiatric Use
Fortunately for patients who suffer foot pain and seek consultation from a medical professional today, there are many noninvasive treatment options. Where steroid injections and oral pharmaceuticals were the norm until fairly recently, now topical medications are gaining ground, particularly with podiatrists. Compounded topical agents are favored, for a number of reasons:
- Multiple drugs can be compounded together in one application, such as a transdermal gel or patch. This reduces the number of pills patients need to take and makes treatment simpler, which in turn improves patient compliance and adherence to therapy. Unlike with commercial combinations, however, compounded medications aren’t locked into fixed doses, so the most efficacious doses can be exactly prepared.
- Topical drugs apply a concentration of product where it is needed and virtually none where it is not.
- Serum concentrations with topical medications are generally in the 5-15% range, which is significantly lower than with oral medications. This means far fewer adverse events and drug-drug interactions, a concern for all patients, but especially those who are on a long list of medications.
- Patients who are on anticoagulation therapy have less worry about affecting their protimes with topical NSAIDs than with oral. And they can avoid the risk of GERD or ulcers as well.
Conditions Where Topical Medications Are Effective in Podiatry
There are many conditions in which topical medications are currently being used in podiatry:
- plantar fasciitis (AKA plantar fasciosis or plantar fasciopathy)
- achilles tendinosis
- heel keratosis
- diabetic neuropathy
- hallux limitus with osteoarthritis
- interdigital neuroma
- dorsal nerve entrapment
- wound care
- acute injuries
While a great deal of focus in research and anecdotal literature has been on seniors and patients with chronic illnesses, not all prescriptions are for people in those categories. Athletes, especially runners, are another market for topical podiatric medications.
Drug Choices in Treating Foot Pain
Because of the relative freedom from side effects and drug interactions with topical medications, practitioners have greater latitude in choosing and combining drugs. NSAIDs are very well studied, and flurbiprofen and ketoprofen are frequently prescribed. Often an anesthetic, such as lidocaine, is added, as well as an anticonvulsant like gabapentin.
Verapamil, a calcium channel blocker also used most often to treat high blood pressure and cardiac arrhythmias, is being utilized more and more in the treatment of plantar fibromatosis, also called Ledderhose disease. Calcium is needed in the production of fibromas. Calcium channel blockers reduce production of collagen and fibronectin in fibroblasts, the cells that manufacture fibromas. They also assist in the breakdown of collagen in keloids, and it is thought the same mechanism takes place in plantar fibromas.
Transdermal verapamil in a 15% gel can be obtained from a compounding pharmaceutical provider like PNA, and the advantage to having it compounded is that it can be combined with other medications, as needed.
Recommendations for the Future
More studies need to be done on the future of topical medications for podiatric applications. Meanwhile, here are some recommendations for treatment in the near future:
- While the side effect profile of topical medications is minimal, patients still need to be monitored for adverse events. When in doubt, start patients on low doses and titrate up in small increments.
- Likewise, drug interactions should be checked, especially in patients on anticoagulation therapy taking NSAIDs.
- Document results in newsletters and trade journals so peers can draw on your anecdotal experience outside of academic literature.
- Explore adjuvants to enhance topical treatments, such as ultrasound and heat, as well as carrying agents for the best penetration and delivery with the fewest side effects.
Pharmaceutica North America is your source for compounding verapamil and flurbiprofen for podiatric use. To enhance your treatment of foot pain, please contact us to discuss how you can custom make topical prescriptions with multiple medications in one delivery source.