Compounding pharmacies have been in the news a lot in recent years, from illegal formulations to mathematical errors. Compounders have developed something of a murky reputation as a result, but reputable outlets can often play a vital role in a horse's treatment plan—the trick is distinguishing the difference between those that cut corners and those that don't.
Veterinarians may prescribe a compounded drug in any number of circumstances, according to Dr. Bart Barber, veterinarian and owner at Rood and Riddle Veterinary Pharmacy. A compounder can provide a needed medicine in a form that is easier for owners to administer or can add flavoring to make medicine more palatable (apple and alfalfa flavors are popular for horses). But Barber said the biggest reason to use a compound is when there's a gap between what manufacturers can produce and what the horse requires—when something is on backorder or has been discontinued.
“If there's a parent drug that is available, you should be using that,” said Barber, who noted that compounders can add flavoring to manufactured drugs like Banamine (flunixin) and should only be making flunixin themselves when the manufactured form is unavailable.
There are rare instances when an animal would benefit more from receiving two drugs together in one compounded medication than from giving them separately. Unless there are unique circumstances, Barber said, horsemen should be using the commercially-available items according to their veterinarian's directions.
When a compounded medication is needed, the Internet is only too happy to provide. Fortunately, there are a few key questions owners and managers can ask to determine which outlets are safest:
- Are they offering to provide compounds or “supplements” without divulging the ingredients? Are they offering products said to contain prescription drugs without requiring a prescription? This is not only an unsettling prospect from a regulatory standpoint, there's no guarantee the product will work. The Food and Drug Administration tests and inspects veterinary drugs like bute and flunixin, but not supplements, so there's no way to be sure the product contains the amounts of prescription drugs it claims to.
- Do they list compounded versions of drugs already on the market for bulk sale? “Saving money is never a reason to use a compound over a manufactured drug,” said Barber, though that's often why people opt for compounded versions of drugs like the ulcer medication omeprazole. “If a manufactured drug exists and they're offering to sell that to you as a compound, they're cutting corners and it's hard to tell where else they may be cutting corners,” he said.
- Check whether the pharmacy is accredited through the Pharmacy Compounding Accreditation Board (PCAB) or, for online sellers, if it has a Verified Internet Pharmacy Practice Sites (VIPP) certification. PCAB certifies that a pharmacy has gone beyond the licensing requirements necessary in its state of business and vouches both for scientific and business practices. PCAB pharmacies must be in good standing and have proper licensing in their state and pass a series of inspections ensuring staff competency, facilities and equipment function, thorough record-keeping, and use of FDA-registered or licensed sources. VIPP outlets must demonstrate they can maintain patient/client privacy and a secure ordering system, stick to a recognized quality assurance program, and keep a dialogue open between pharmacists and patients/clients. Also, remember some online storefronts have physical locations that could have additional certifications.
- Find out how much voluntary testing goes on within the facility. At Rood and Riddle Veterinary Pharmacy, a third party laboratory regularly tests sterile compounds for contamination and potency to ensure the medication is safe and has the concentration advertised on its label. Clients should be able to call a pharmacy with a lot number and request to see the results of such tests.
- Ask about stop-gap procedures to avoid human error. In a couple of recent news stories, human or mathematical errors were blamed for contaminated products. Barber said one thing pharmacies can do to minimize this is to have pharmacists and technicians check each other's work when weighing ingredients for a batch of compounded medication—and keep track of who checked off on what.
- Ask whether they've made this product before. “One thing that protects us is we only make things that we're comfortable making,” said Barber, who pointed out that experience with commonly-requested drugs helps pharmacy staff recognize a problem quickly—if a decimal point or number is out of place in a calculation, it should stick out. “It's more likely that I as a veterinarian could make a mistake pulling up the amount of the medication than that [the pharmacy] could make a mistake here,” he said.
- Don't be afraid to do your own testing. A pharmacy that works hard to maintain good practices shouldn't mind consumers ordering their own laboratory to test a compounded product. It's an investment on the consumer's part, Barber said, but it can provide peace of mind, especially in cases where a horse might require a medication long-term for a chronic condition.
- When in doubt about an online retailer, ask your veterinarian or a trusted pharmacist to look at the labeling. If you're shopping for compounders but know a non-compounding pharmacist that you trust, have them look things over.
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