Compounding Pearls Member Panel

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2 Disclosure Mike Collins, RPh, is the owner of Healthway Compounding Pharmacy. Diane Boomsma, PharmD, FIACP, is the owner of Custom Prescriptions of Lancaster. Professional Education Services Group staff have no financial interest or relationships to disclose All Rights Reserved. 2

Neither PESG nor any accrediting organization supports or

3 Disclosure This continuing education activity is managed and accredited by Professional Education Services Group. Neither PESG nor any accrediting organization supports or endorses any product or service mentioned in this activity All Rights Reserved. 3

5 Learning Objectives At the conclusion of this activity, the participant will be able to: Discuss some of the more commonly prescribed compounded formulas in areas such as mucositis, wound care, otitis, sinus, and women s health. Review patient case studies to determine the best course of treatment. Discuss compounds and nutritional supplements that can be used in treatment of hormones, thyroid, and the adrenals All Rights Reserved. 5

9 Ulcers of the Mouth Mucositis or Apthous Stomatitis Our go to formula we call Oral Rinse No. 5 We usually dispense 120 ml 240 ml 5 ml swish and spit four times daily We keep it in stock, make ml every Monday It is usually a stat dispense. Dentists send them in after a visit All Rights Reserved. 9

10 Ulcers of the Mouth Oral Rinse No mL formulation Doxycycline hyclate 0.472g Nystatin, USP g Triamcinolone acetonide 0.1g Chlorpheniramine maleate 0.02g Deoxy D Glucose (2) 0.1g Simethicone, USP 2mL Stevioside 15% liquid ext 2.4mL Water (distilled) 5mL Magnasweet 1mL Sorbitol solution 70% (w/w) 70.7mL Oral suspending base 18mL All Rights Reserved. 10

12 KLMP Formula KLMP + Minocycline 100g formulation Ketoprofen powder, USP Lidocaine hydrochloride, USP 2g 2g Aloe Vera powder, freeze dried 0.2g Misoprostol 1% 0.3g Phenytoin powder, USP Propylene glycol liquid Oral adhesive paste Minocycline hydrochloride NOTES: Dispense in ointment tube 2g 5mL qs 100mL 1g All Rights Reserved. 12

13 Lollipops Nicotine 2mg, 4mg Tetracaine Most popular is 0.5%. Use for 5 10 seconds PRN We usually dispense 2 3 per prescription Marketed to dentists, radiation oncology centers, otorhinolaryngologists All Rights Reserved. 13

15 The Accordion Puffer Wound care with polyox bandage Chlorophyll sodium copper complex 1% / lidocaine 1% / metronidazole 1% Chlorophyll sodium copper complex 1% / clotrimazole 1% / metronidazole 2% Ketoprofen 2% / misoprostol 0.003% / phenytoin 2% Polyox sticks to all mucosal surfaces as well Excellent device for otic powders also All Rights Reserved. 15

17 Otitis Case 45 year old male with chronic draining ear. He would have to clean out every 2 hours and said it felt like a runny nose in my ear. Tried several ear drops and oral antibiotics, but nothing helped. Patient went to ENT specialist and doctor prescribed otic powder Usually dispense 5g in accordion puffer Patient used 2 3 puffs in ear twice daily. Ear cleared up after 1 week of use, now uses it just when symptoms arise. Patient is very happy All Rights Reserved. 17

19 Sinus Irrigations Formulas are dispensed in capsule form Patient opens capsule, mixes with distilled water, rinses with 60mL through each nostril Formulas may include: Tobramycin, vancomycin, betamethasone, and proprietary xylitol based filler All Rights Reserved. 19

20 Sinus Rinse Case MH 60 year old female was diagnosed with chronic sinusitis. Patient described nose runs all the time with terrible sinus congestion. She was on many courses of steroids and antibiotics and had to stop due to bone loss. Doctor prescribed Betamethasone 0.5mg / Tobramycin 10mg / Vancomycin 20mg in Xylitol filled capsules Patient is using one capsule and irrigating with rinse bottle every morning, controls symptoms, but not cured All Rights Reserved. 20

21 Sinus Rinse Case Sinus rinse per capsule formulation Betamethasone Sod Phosphate Tobramycin Vancomycin 0.5mg 10mg 20mg Xylitol 0.58g NOTES: Size 0 capsule Calculate tobramycin and vancomycin based on activity Don t seal capsule so they can be pulled apart All Rights Reserved. 21

23 Cracked Nipple Treatment 4 Also known as Newman s Nipple cream Jack Newman MD, FRCPC, started the first hospital based breast feeding clinic in Canada. Contains: Betamethasone Valerate 0.025% Nystatin 100,000 U/g Mupirocin 0.5% Clotrimazole 0.25% ointment Apply pea size amount to cracked nipples after each feeding All Rights Reserved. 23

24 Cracked Nipple Treatment Cracked Nipple Treatment 60g formulation Betamethasone Valerate 0.018g Clotrimazole, USP 0.15g Mupirocin 0.3g Nystatin, USP 0.238g Mineral Oil heavy 1mL Aloe Vera Powder, freeze dried 0.3g Plasticized Base Petrolatum White 15g qs to 60g NOTES: Mix with EMP then run through the ointment mill then EMP again All Rights Reserved. 24

25 Cracked Nipple Case 25 year old female 15 days post partum, first baby, cracked and bleeding nipples from breastfeeding Doctor prescribed: Betamethasone 0.025% Clotrimazole 0.25% Mupirocin 0.5% Nystatin 30,000 U/g Mineral oil 1mL Aloe vera powder 0.3g Plasticized base 15g Petrolatum qs 60g All Rights Reserved. 25

26 Cracked Nipple Case (cont d) Patient applied pea size amount of ointment onto each nipple about 5 times daily. Nipples were almost clear in 2 days and patient continued nursing throughout whole treatment period All Rights Reserved. 26

27 Vulvodynia Literally means vulvar pain: burning, rawness, soreness, irritation, sensitivity, etc. The diagnosis depends on lack of documented infections or dermatologic cause. Should be suspected in any patient with more than 3 months history of pain at the introitus or vulva. Treatment is a multi disciplined approach All Rights Reserved. 27

28 Vulvodynia 5 The Vulvodynia Guideline 2000 Journal of Lower Genital Tract Diseases Volume 9 Number 1, 1005, with Dr. Hope Haefner at the University of Michigan. Topical analgesics used by U of M Medication Strength Directions Amitriptyline/Baclofen Transdermal 2%/2% Gabapentin Transdermal 6 10% Ketamine Transdermal 10 20% Baclofen/Guaifenesin/Ketoprofen 2%/10%/20% Doxepin Transdermal 5% Lidocaine base/prilocaine base 2.5%/2.5% Lidocaine ointment 5% Apply once to three times daily Apply once to four times daily Apply once to four times daily Apply once to twice daily Apply once to four times daily Apply once to four times daily Apply twice daily as needed All Rights Reserved. 28

30 Vulvodynia: Case Study 1 BK presented at age 39. She is a G2P2 who presented to the Center for Vulvar Diseases in year history of vulvar irritation. Her vulva is red and swollen. It gets raw, burns, and she has itching. Fissures and occasionally blisters Pain following intercourse. It hurts when semen touches it. She uses McGill descriptors of a sharp, burning, stinging, hurting, splitting, fearful, unbearable, penetrating, tearing pain. Things that help it are cold, loose clothing, lack of underwear, Vaseline All Rights Reserved. 30

31 2010 Physical Examination There was no groin lymphadenopathy. The labia majora, labia minora, prepuce, clitoris, vestibule, perineum, and anus did not have any suspicious areas requiring a biopsy. Cotton swab testing revealed pain localized to the vestibule (mild at the 2, 4, and 8 o'clock positions and moderate at the 6 o'clock position) Fissure near the 7 o'clock position Inclusion cyst at the 6 o'clock position All Rights Reserved. 31

32 Laboratory Studies Candida albicans positive Fluconazole was prescribed 90% improvement on fluconazole She still does have sensation of itching and burning that starts two days prior to her menses She no longer has any skin fissures or ulcerations All Rights Reserved. 32

33 Treatment Therapeutically, we recommended the patient continue to use 5% lidocaine ointment PRN prior to intercourse. Prescribed the patient a compounded amitriptyline 2% and baclofen 2% ointment in topical cream base (apply at night and can titrate up to 3 times per day if needed) Recommended a silicone based lubricant at the time of intercourse Patient also met with social worker to discuss sexual dysfunction All Rights Reserved. 33

34 2012 Patient presents with dyspareunia Pain with insertion Less pain with the use of lidocaine jelly prior to intercourse as well as use of condom Pain is improved using Amitriptyline HCl 2% / Baclofen 2% vaginal cream All Rights Reserved. 34

35 2013 Patient has pain at the vestibule that is small and a probable inclusion cyst Inclusion cyst removed She continues to benefit from the amitriptyline 2% / baclofen 2% in topical cream base All Rights Reserved. 35

36 % improved on Amitriptyline 2% / Baclofen 2% Vulva: no groin lymphadenopathy. Normal majora, labia minora, clitoris, prepuce, perineum, and anus. Q tip testing significant for minor pain at the 3 o'clock position of the vestibule All Rights Reserved. 36

Lichen Planus 6 Autoimmune condition that can affect the skin, oral mucosa, genitalia, scalp, nails and esophagus that is mediated by CD8+ T cells due to an unknown

38 Lichen Planus 6 Autoimmune condition that can affect the skin, oral mucosa, genitalia, scalp, nails and esophagus that is mediated by CD8+ T cells due to an unknown antigen LP can also develop due to medications (e.g. NSAIDS, anti hypertensives, antimalarial agents, Hepatitis B vaccine, P2Y 12 antagonist) All Rights Reserved. 38

39 Oral Lichen Planus Formula Oral Rinse No mL formulation Doxycycline hyclate 0.472g Nystatin, USP g Triamcinolone acetonide 0.1g Chlorpheniramine maleate 0.02g Deoxy D Glucose (2) 0.1g Simethicone, USP 2 ml Stevioside 15% liquid ext 2.4mL Water (distilled) 5mL Magnasweet 1mL Sorbitol solution 70% (w/w) 70.7mL Oral suspending base 18mL All Rights Reserved. 39

40 Lichen Planus Vaginal Formulas Hydrocortisone 100mg/g use 5g vaginally QD x 7 days, 4g QD x 7days, 3g QD x 7days, 2g QD x 7days, then 1g QD until seen Or use HC 50mg suppository 1 BID x 2weeks, QD x 2 weeks, then QOD (on off day use Tacrolimus 2 mg suppository) Or Tacrolimus 0.1% / Diphenhydramine 2% / Tranilast 2% apply a thin layer to vulva daily x 2 weeks. Reference: Hope Haefner, MD University of Michigan Vulvar Pain Group All Rights Reserved. 40

42 Vaginal Lichen Planus 73 year old female G5P5 presents with concerns of lichen planus and labial fusion Feb 2014 exam noted labial fusion. Reports two UTIs in June and July. Physical exam: Oral: Wickham s striae, redness around gums consistent with lichen planus Vulva: complete scarring of labia over vagina with 1 cm opening. Q tip can be inserted to 4 cm. ¼ dilator can be inserted without difficulty All Rights Reserved. 42

43 Vaginal Lichen Planus Oct 2014: adhesions opened with manual traction. Redness consistent with lichen planus. Patient instructed to dilate daily and use topical steroids. Jan 2016: significant erosive lichen planus changes around the introitus. Fusion of the prepuce over clitoris. Speculum inserted into vagina and lichen planus was found as well as erosions. Continued topical triamcinolone varying between 0.5% and 0.1%. For vaginal use, compounded hydrocortisone 2.5% All Rights Reserved. 43

44 Atrophic Vaginitis 7 Common in post menopausal women Symptoms: dryness, itching, irritation, burning, and / or dyspareunia May also have urinary symptoms (e.g. urgency, frequency, nocturia, dysuria, incontinence, recurrent urinary tract infections) All Rights Reserved. 44

45 Atrophic Vaginitis Estrogen formulas Estriol 0.25 mg/g Estriol 0.05 mg/g + Estradiol 0.05 mg/g Estradiol 0.1mg/g + progesterone 10 mg/g NOTES: In cream base Dispense in 60g tube Dispense with applicator 2g is usual dose Non hormonal option Hyaluronic Acid 5mg/g Aloe Vera Freeze dried 5mg/g Poloxamer 30% 66gm Topical gel base qs 100g NOTES: Dispense in 60g tube Dispense with applicator Use 2 5 g PRN All Rights Reserved. 45

46 Trichomonas vaginalis 8,9 A protozoan sexually transmitted disease with humans being only known host. Can increase vaginal ph to >5. Current treatment: metronidazole Treatment of partner highly recommended Boric acid capsules inserted vaginally as alternative when treatment fails. Has demonstrated bactericidal activity to Trichomonas at ph ranges of 5 7. Boric Acid 600 mg 100 capsule formulation Boric Acid powder, NF Capsule #00 Proprietary blend of probiotic powder 60g 100 capsules 12.5g All Rights Reserved. 46

47 Case from Follow Up Call Patient began using boric acid capsules vaginally in Sept and has refilled monthly. Patient uses capsules every other day unless symptoms present. Uses daily for 3 5 days until symptoms resolve. When asked patient if she was interested in using boric acid in a suppository, she stated that the capsules were working well and did not want to change the formulation All Rights Reserved. 47

49 Anal Fissure Cream 10 Our formula does not have official studies, but used on hundreds of patients over 8 years. Our surgeons tell their patients this formula will cure ½, the other ½ need surgery. Nitroglycerin 0.2% / Misoprostol 0.002% / Phenytoin 0.2% / 1,3 beta glucan 1.7% in plasticized base Apply pea size amount to affected area bid Nifedipine 0.2%: 141 patients treated every 12 hours for 3 weeks. Total remission in 95% of patients in 21 days All Rights Reserved. 49

50 Diazepam Suppositories Female patient referred to physical therapy due to pelvic pain with 4 years of duration. Diagnosed with Tarlov cysts that were surgically removed in 2013, but returned in Patient fell and fractured coccyx in Pain increased and received injections with no relief. Developed constant sensation of having to evacuate her bowels. Experienced constipation and bearing down caused severe rectum pain. Pain described as 10/10. Found to have impaired pudendal nerve All Rights Reserved. 50

51 Diazepam Suppositories (cont d) Medications: methadone, gabapentin, laxatives After 2 doses of rectal diazepam suppositories, patient had 50% less pain in rectum and no longer felt sensation of having BM. After 2 weeks, the pain worsened and instead switched to using suppositories vaginally which reduced the pain to a functional level All Rights Reserved. 51

54 Topical Anesthetics Quadcaine: Bupivacaine1% / Lidocaine 10% / Prilocaine 5% / Tetracaine 5% / DMSO 42% qs with Ethyl Alcohol We only dispense max of 5 ml in a bottle Market to all the laser centers, permanent make up artists, hair removal centers, etc All Rights Reserved. 54

55 Low Dose Naltrexone (LDN) 12,13 Studied either clinically or anecdotally in patients experiencing chronic pain syndromes such as fibromyalgia, complex regional pain syndrome (CRPS), respectively. U.S. FDA indications: treatment of alcohol and opioid dependency. Typical dose is 50 mg orally QD Doses used for pain syndromes: 1.5 mg, 3 mg, or 4.5 mg orally QD All Rights Reserved. 55

56 LDN Case for CRPS Type I 17 year old female presents to pain specialist clinic for secondary consult due to left lower extremity pain lasting over the course of 3 years Pain started without known etiology, but was exacerbated after spraining ankle Diagnosis: complex regional pain syndrome, type I Symptoms included: allodynia, left extremity colder than right, pain primarily located in left foot and slightly radiated above the knee (VAS 8 out of 10) All Rights Reserved. 56

57 LDN Case for CRPS Type I (cont d) Trialed therapies: lumbar sympathetic blockade, physical therapy, multiple neuroleptic medications After failed trial of clonidine transdermal and nortriptyline, started naltrexone 1.5 mg orally at bedtime At 4 weeks follow up, patient reported VAS score of 1 out of 10 and able to wear shoe on affected limb All Rights Reserved. 57

Hemorrhoids I/O Suppository (Rectal Rocket): Hydrocortisone 2% / Lidocaine

Questions? Call / Email Us Healthway Compounding Pharmacy 2544 McLeod Drive North Saginaw, MI 48604 989 791 1691 www.healthwayrx.

59 Questions? Call / Us Healthway Compounding Pharmacy 2544 McLeod Drive North Saginaw, MI Michael Collins, RPh, FIACP mcollins@healthwayrx.com Amy Dwyer, RPh, CN adwyer@healthwayrx.com Carrie Wilson, PharmD cwilson@healthwayrx.com All Rights Reserved. 59

60 References 1. Kincaid M. Options in wound care. International Journal of Compounding Pharmacy. 2002;6(2): Wynn T, Thompson C. Case report: wound care of a diabetic foot ulcer. International Journal of Compounding Pharmacy. 2004;8(4): Medicated polyox bandage for skin ulcers. International Journal of Compounding Pharmacy. 2016;20(2): International Breastfeeding Centre. All purpose nipple ointment. 76:all purpose nipple ointment apno&catid=5:information&itemid=17 (accessed 2016 Mar 30) All Rights Reserved. 60

61 References 5.Haefner HK, Collins ME, Davis GD, et al. The vulvodynia guideline. J Low Genit Tract Dis Jan;9(1): Dudbia BB, Dudhia SB, Patel PS, et al. Oral lichen planus to oral lichenoid lesions: Evolution or revolution. J Oral Maxillofac Pathol Sep Dec;19(3): Goldstein I, Dicks B, Kim N et al. Multidisciplinary overview of vaginal atrophy and associated genitourinary symptoms in postmenopausal women. Sex Med Dec;1(2): All Rights Reserved. 61

62 References 8. Kissinger P. Trichomonas vaginalis: a review of epidemiologic, clinical and treatment issues. BMC Infect Dis Aug 5;15: Brittingham A, Wilson WA. The antimicrobial effect of boric acid on Trichomonas vaginalis. Sex Transm Dis Dec;41(12): All Rights Reserved. 62

63 References 10. Antropoli C, Perrotti P, Rubino M, et al. Nifedipine for local use in conservative treatment of anal fissures: preliminary results of a multicenter study. Dis Colon Rectum 1999 Aug;42(8): Younger J, Parkitny L, McLain D. The use of low dose naltrexone (LDN) as a novel anti inflammatory treatment for chronic pain. Clin Rheumatol Apr;33(4): Younger J, Noor N, McCue R, et al. Low dose naltrexone for the treatment of fibromyalgia: findings of a small, randomized, doubleblind, placebo controlled, counterbalanced, crossover trial assessing daily pain levels. Arthritis Rheum Feb;65(2): All Rights Reserved. 63

64 References 13. Lee MWC. Topical triple anesthetic gel compared with 3 topical anesthetics. Cosmetic Dermatology 2003 Apr;16(4): Silverberg NB, Lim JK, Paller AS, et al. Squaric acid immunotherapy for warts in children. J Am Acad Dermatol May;42(5 Pt 1): Hirose R, Hori M, Shukuwa T, et al. Topical treatment of resistant warts with glutaraldehyle. J Dermatol 1994 Apr;21(4): All Rights Reserved. 64

65 References 16.Romiti R, Ribeiro AP, Romiti N. Evaluation of the effectiveness of 5% potassium hydroxide for the treatment of molluscum contagiosum. Pediatr Dermatol Nov Dec;17(6): Romiti R, Ribeiro AP, Grinblat BM, et al. Treatment of molluscum contagiosum with potassium hydroxide: a clinical approach in 35 children. Pediatr Dermatol 1999 May Jun;16(3): All Rights Reserved. 65

67 My Bread n Butter Philosophy Women have long been the undisputed family health care decision makers, making approximately 80% of family health care choices They also choose their children s doctors (85%) Take them to appointments (84%) Ensure they get recommended care (79%) * Kaiser Family Foundation Report from May All Rights Reserved. 67

68 My Bread n Butter Philosophy Women s health care influence has moved beyond the family. Nearly 70% of women use social networking sites, where they influence the health care decisions of the women in their online communities and those of their families. Nearly half of consumers said social media derived information would affect their health care decisions. So each Facebook update, online community post or tweet has the potential to change minds and change behavior. * newsletters/june 2012/women influence health care decisions/ All Rights Reserved. 68

69 My Bread n Butter Philosophy As our population ages, the number of postmenopausal women grows. It is estimated that in 1998, there were over 477 million postmenopausal women in the world. That number is projected to rise to rise to 1.1 billion by the year Ten percent of women said they were irritable, fatigued, and had feelings of despair during the menopausal phase of their lives. * statistics infographic# All Rights Reserved. 69

70 My Bread n Butter Philosophy Target information and treatment options for 1. Hormone treatment 2. Thyroid support and treatment 3. Adrenal support and / or treatment 4. Build your consultation business All Rights Reserved. 70

72 Progesterone Compounds Micronized capsules sleep, regulation of menorrhagia and cycle length, easy to blood test Troches up to 400mg fertility the best Sublingual drops in an oil base flexible. Used to stop a migraine or mood stabilization. Clear vaginal capsules / vaginal suppositories up to 400mg Transdermal creams 1mL max application Injectables advantage of less volume All Rights Reserved. 72

73 Vaginal Suppositories Still first choice for pregnancy over other progesterone dosage forms MBK base cheese grater technique Cocoa butter base Do not overheat base (50 C 55 C) RAM powders All Rights Reserved. 73

74 Troche Tricks Bitter Stop 0.1mL per 30 progesterone Premade troche base Hot spatulas especially with gelatin Mint is the best flavor with progesterone Premade excipient base acacia, silica, steviosides, acesulfame potassium Pre grind citric acid Double strength dose = ½ troche Combine multiple API s RAM weigh silica first, add APIs All Rights Reserved. 74

75 Transdermal Cream Considerations See chart in the app Pumps 0.12gm, 0.5gm, 1gm Topi click 0.25gm Cream selection allergy consideration Use of aliquot hormone concentrates Combine multiple APIs Facial application All Rights Reserved. 75

76 Estrogen Compounds Estradiol Tablets commercially available. ½ 1 tablet sublingually. Oral estradiol bioavailability is about 5% bioavailability of sublingual estradiol is about 25% Troches advantage is the combination of APIs or custom strength Topical creams advantage is combination of APIs, custom strength, cost, amount applied, add to cosmetic facial creams Vaginal cream allergy to ingredients with commercial products, patient access to commercial medications, custom strength, combine with hyaluronic acid, package for ease of use All Rights Reserved. 76

77 Estrogen Compounds Estradiol (cont d) Vaginal capsule custom strength Vaginal oil chemically sensitive patients Injectable alternative to castor oil (commercial product currently on backorder) All Rights Reserved. 77

79 Testosterone Capsules methyltestosterone 0.25mg 0.5mg Mini troches 0.5mg, 1mg, 2mg Troches less labor, combine API s Vaginal capsules Vaginal ointment lichen sclerosus Vaginal cream Transdermal cream All Rights Reserved. 79

81 BHRT Men If the testes are functional use them test LH. If borderline or low, use clomiphene 25mg 50mg every other day to daily. HCG in place of clomiphene Use testosterone only if there is a diminished testicular capacity for output Testosterone + HCG + Anastrazole (T Treatment Trifecta) All Rights Reserved. 81

82 Sample Regimen Testosterone treatment dosages for men 50mg Testosterone cypionate every third day 0.25mg anastrazole every third day 500IU HCG every third day (clomiphene) All medications taken on the same day All Rights Reserved. 82

83 Breast Cancer Options Ergot / belladonna leaf / phenobarbital capsules Vitamin E vaginal suppositories Methyltestosterone capsules Vitamin A / E / hyaluronic acid vaginal gel All Rights Reserved. 83

85 Compounding Thyroid Download formula for the lot of chemical that you have Use a tracer such as folic acid or riboflavin Add tracer directly to the container Only use a glass mortar and pestle. Use microcrystalline cellulose as a diluent Coat mortar first with small amount of microcrystalline cellulose Add small amount of microcrystalline cellulose to Thyroid container Continually wash container until powder is white Test potency of aliquot All Rights Reserved. 85

86 Dietary Supplements for Adrenal Fatigue Vitamin C 2,000 5,000 mg/day 1:2 ratio of bio flavonoids to C Vitamin E with mixed tocopherols 800 IU/day Pantothenic acid (B5) 1500 mg daily Calcium (malate / citrate) 800 mg Magnesium (glycinate / citrate) 400 mg Organic trace minerals calming effect Digestive aids will be needed by most until recovery is more complete All Rights Reserved. 86

87 Nutritional / Vitamins Vitamins / supplements: 1. Just a B complex with vitamin C (or maybe a B 50 w/c or B 100 w/c) 2. Extra B 5, 250 to 500mg once or twice daily 3. Super Adrenal Stress Formula 4. Adrenal C Formula All Rights Reserved. 87

88 Adaptogens Ashwagandha Holy Basil Siberian Ginseng Licorice Maca Rhodiola Relora Cordyceps Bacopa Used to control high or fluctuating cortisol levels without dropping normal or low levels All Rights Reserved. 88

89 Adaptogens Adaptogens: 1. Siberian Ginseng 250 to 500mg 1 or 2 times daily 2. Ashwagandha (Indian Ginseng) ~300mg 1 or 2 times daily 3. Rhodiola (Rhodiola rosea) 100 to 250mg 1 3 times daily 4. Herbal Adrenal Support Formula drops 5. Magnolia and Phellodendron extract 200mg 3 times daily All Rights Reserved. 89

Compounding Options for Female and Male Patients

Compounding Options for Female and Male Patients Bruce Biundo, RPh and Andrea Branvold, RPh 2016 Las Vegas Hormone Replacement Therapy Symposium Las Vegas, NV February 11 13, 2016 Men s Health: Treating