Compounding Problem Solving

N-acetylcysteine to Decrease the Incidence of Contrast-Induced Renal Failure
Following Cardiac Catheterization, CT scan, Angiography, etc.

Radiocontrast–induced nephropathy (RCIN) is a preventable complication of administration of radiocontrast agents used in procedures such as cardiac catheterization, CT scan, angiography, etc. RCIN has been reported to be the third most common cause of renal insufficiency occurring in hospitalized patients. Patients who are at greatest risk of RCIN are those with renal insufficiency, such as patients with diabetic nephropathy or advanced congestive heart failure. The effects of RCIN are usually seen within 72 hours of administration and can range from a transient slight increase in serum creatinine levels to acute renal failure.

Tepel et al. concluded that prophylactic oral administration of the antioxidant N-acetylcysteine (600 mg orally twice daily) and 0.45 percent saline intravenously, before and after administration of the contrast agent, prevents the reduction in renal function induced by contrast agents in patients with chronic renal insufficiency.¹ Duong et al. used standard search protocols to identify all published articles and abstracts of prospective trials using N-acetylcysteine (NAC) with fluid hydration compared to hydration alone in patients with chronic renal insufficiency undergoing contrast procedures. A rise in serum creatinine by 0.5 mg/dl or 25% above baseline at 48-72 hr after contrast exposure was used as the primary outcome. Fourteen trials of NAC with 1,584 patients published as full-text articles met inclusion criteria for the meta-analysis. Treated patients received 600 mg p.o. b.i.d. × 2 days of NAC, or equivalent dosing, in 12/14 trials. One study used 1,200 mg p.o. b.i.d. × 2 days and another used 2 g b.i.d. × 3 doses. The analysis concluded that the use of oral NAC resulted in a significant reduction in the risk for developing RCIN.² Baker et al. report that administration of intravenous NAC should be considered in all patients at risk of RCIN before contrast exposure when time constraints preclude adequate oral prophylaxis, provided the patient is able to tolerate the volume loading.³

Oral N-acetylcysteine, along with hydration with 0.45% sodium chloride solution, is gaining acceptance as “a promising preventive protocol for RCIN. N-acetylcysteine is well tolerated by patients: no major side effects have been reported. Compounding pharmacists can play an important role in preventing RCIN by compounding N-acetylcysteine into a palatable capsule form that will improve patient compliance and by counseling patients on the importance of keeping hydrated prior to contrast medium procedures.”⁴

¹ N Engl J Med 2000 Jul 20;343(3):180-4. Click here for abstract.

² Catheter Cardiovasc Interv. 2005 Apr;64(4):471-9. Click here for abstract.

³ J Am Coll Cardiol. 2003 Jun 18;41(12):2114-8. Click here for abstract.

⁴ Int’l Journal of Pharmaceutical Compounding, Mar/Apr 2005; 9(2):99-103

Call our compounding pharmacy when a needed medication is not commercially available.

Topical glycopyrrolate 0.5% solution is effective in treating craniofacial hyperhidrosis
and is associated with few adverse effects.

South Med J 2002 Jul;95(7):756-8
Craniofacial hyperhidrosis successfully treated with topical glycopyrrolate.

Luh JY, Blackwell TA.
Department of Internal Medicine, University of Texas Medical Branch at Galveston, 77555-0570, USA.

Click here to read the PubMed abstract.

“All purpose nipple ointment” (APNO) is a combination of 3 ingredients which seems to help for many causes of sore nipples during breastfeeding. Cracks and erosions in the nipple harbor bacteria that can cause infection or delay healing. In addition, the presence of Candida albicans can cause nipple soreness and cracking. Inflammation associated with infection or injury can cause significant pain. “It is always good, however, to try to assure the best latch possible, because improving the latch helps with any cause of pain.”

Jack Newman, MD, FRCPC, a pediatrician, started the first hospital-based breastfeeding clinic in Canada in 1984. He has been a consultant with UNICEF for the Baby Friendly Hospital Initiative in Africa. Dr. Newman notes that ointments work better than creams to treat sore nipples, and recommends a preparation containing mupirocin 2% ointment 15 grams, betamethasone 0.1% ointment 15 grams, with miconazole powder added so that the final concentration is 2% miconazole. Dr. Newman suggests that sometimes it is helpful to add ibuprofen powder as well, so that the final concentration of ibuprofen is 2%. The combination is applied sparingly after each feeding. According to Dr. Newman, “in Canada, Kenacomb™ (easier to find) or Viaderm KC™ (less expensive) ointments (not cream) can be substituted for the above combination, but are distinctly inferior.”

http://www.breastfeedingonline.com/newman.shtml accessed March 29, 2007