In-Office Compounding of Transdermal NSAIDs: Fewer Side Effects for Post-Op Pain

In-Office Compounding of Transdermal NSAIDs: Fewer Side Effects for Post-Op Pain

i-clipboardImagine this case scenario: a fit and healthy patient has had a hiatal hernia repair in day surgery, but cannot yet leave the hospital due to her post-op pain. What analgesic is appropriate? Oral acetaminophen/paracetamol and NSAIDs are the standard go-to’s in hospitals. However, considering the adverse effects that these drugs can render on the GI tract, are either appropriate for a patient recovering from surgery conducted on the hiatus?1 Furthermore, seeing as the opening of the diaphragm was just cut into, what if swallowing pills is simply not an option?

Insufficient Pain Control

Proficient pain control is crucial—not only to avoid pain, but also because unmanaged pain after surgery has actually been linked to higher rates of long-term post-op pain.2 One cause of insufficient pain control is that practitioners often underestimate patients’ discomfort, and therefore underestimate how much drug to administer. When patients are actually carefully questioned by practitioners, they are found to have higher levels of pain than initially recorded. However, even when it is found that higher dosages of analgesics are needed, the side effects and complications known to accompany them serve as a deterrent from administration.

Pharmacists should talk to doctors about whether each individual patient’s pain level has been accurately reported. In addition to poor pain assessments and the fear of analgesics causing side effects, inadequate hospital staffing and insufficient education among staff are listed among other reported causes of insufficient pain control.3 Emphasize that before in-office compounding of a personalized analgesic treatment because it is essential for you to understand a patient’s unique experience with post-op pain.

Common Analgesic Side Effects

Considering the complications caused by the most common analgesics, it’s no wonder that healthcare providers sometimes err on the side of insufficient pain control. Although post-op pain can be treated with opioids, opioids are known to cause several side effects. Some of these side effects can be treated with antihistamines, but antihistamines are known to worsen some of the other side effects caused by opioids.

While opioids can prolong what already feels to a patient like a never-ending chain of health problems, the severity of other common analgesic side effects is just as odious. The incidence of life-threatening respiratory depression originating from patient-controlled analgesia pumps has reported to be as high as 0.1%.4 Meanwhile, NSAIDs have been linked to about 30% of all drug-related hospital admissions: it’s estimated that 12,000-16,000 Americans die annually as a result of gastrointestinal bleeding caused by NSAIDs.5

So the question remains: once accurate pain assessment actually is determined, what to do? If a patient’s level of post-op pain is so high that benefits of common analgesics outweigh risks, work with doctors to carefully review both the individual’s health history and current pain level. Take both factors into consideration when determining what smallest possible dosage of analgesic will provide sufficient pain relief without complications.

Also consider exactly where a patient’s post-op pain is located and what type of pain they feel in order to determine the best method of administration for the individual. Topical administration of NSAIDs is particularly effective for short-term relief of localized pain.

NSAIDs with Fewer Side Effects: Topical Administration as the Standard Go-To

Topical NSAIDs have been shown to be clinically effective, while carrying a significantly lower risk of side effects than comes with oral NSAIDs. Because topical NSAIDs are absorbed transdermally, little drug actually circulates in the plasma, leading to blood levels that are a fraction of comparable oral doses.

Studies conducted by the National Institutes for Health and Clinical Excellence show that topical NSAIDs are not only an effective method of providing pain relief, especially when pain is localized, but that they are a particularly efficient method of pain relief. Because topical NSAIDs are absorbed transdermally, they quickly reach therapeutic levels in areas underlying the skin where applied. Synovial fluid, muscle, and fascia directly affected during operation can be targeted for pain relief.

Rather than run the risk of creating even more health problems, what reason is there not to use topical NSAIDs as a first line of defense against post-op pain? If for some reason topical administration must be ruled out for an individual, by all means resume careful consideration of what analgesic, what dosage, and what method of administration is in fact most appropriate.

Use the Same NSAIDs Transdermally: Harnessing the Benefits of Ketoprofen and Flurbiprofen

Many of the same NSAIDs that are administered orally to treat post-op pain can also be administered topically. For example, both ketoprofen and flurbiprofen are known to cause gastrointestinal side effects when taken orally, but can be combined with a transdermal base, such as an oil-in-water emulsion that penetrates the skin.

Both ketoprofen and flurbiprofen are examples of handy NSAIDs to have on your shelf at the compounding pharmacy—each is effective, with its own unique properties. Ketoprofen has anti-inflammatory, antipyretic, and analgesic properties; is well-tolerated; and provides a strong level of pain relief for patients experiencing mild to moderate pain. Flurbiprofen has analgesic and anti-inflammatory properties; is indicated for pain relief, tenderness, swelling, and stiffness caused by various conditions; and is effective for moderate to severe acute post-op pain.

Why not combine a transdermal base with some of the same NSAIDs already known to be effective analgesics? Active prep kits that contain NSAIDs along with a base that can penetrate the skin, like an oil-in-water emulsion, allow in-office compounding pharmacists to offer a less risky, and individualized, method of pain relief to post-op patients.

What This Means for Compounding Pharmacists

Considering the complications that analgesics bring, in-office compounding of personalized treatments is particularly favorable when it comes to post-op pain relief. Working with doctors to understand individuals’ health histories, current pain levels, and types and locations of pain, is crucial to determine what analgesics, dosages, and methods of administration are best for each patient.

Keep in mind that topical administration does not come with the side effects that oral administration does and is particularly useful when treating localized pain. Consider combining NSAIDs that you already know to be clinically effective with a transdermal base, as a standard go-to when in-office compounding for post-op pain relief.

Pharmaceutica North America would like to be your source for your in-office compounding needs, including Active Prep Kits and our unique oil-in-water transdermal base, Albaderm. Contact us today to learn more about how we can help your compounding pharmacy meet patientsneeds for topically administered NSAIDs and more.

Show 5 footnotes

  1.  “The Risk of Upper Gastrointestinal Complications Associated with Nonsteroidal Anti-Inflammatory Drugs, Glucocorticoids, Acetaminophen, and Combinations of These Agents,” 2001,
  2.  “Acute Pain after Thoracic Surgery Predicts Long-Term Post-Thoracotomy Pain,” 1996,
  3.  “Acute Postoperative Pain Management,” 2000,
  4.  “Respiratory-Related Critical Events with Intravenous Patient-Controlled Analgesia,” 1994,
  5.  “Topical NSAIDs,” 2011,

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