by Sam Hamburger, PharmD Candidate, PCCA Clinical Services Intern, and Beau Harger, PharmD, PCCA Clinical Compounding Pharmacist/Training Instructor

The fundamental purpose of hospice is to help patients retain comfort, dignity and quality of life as they approach the end of life. During this stage, nausea and vomiting — either caused by medication side effects or from symptoms of a disease — are common. These and other side effects may lead to unnecessary stress and patient discomfort.¹ In the following article, we review a commonly used topical gel that lessens nausea and vomiting,² as well as the PCCA base vehicle that may enhance penetration of active pharmaceutical ingredients (APIs).

ABH Gel: Common & Customized

ABH gel is often used to help patients with nausea, vomiting and delirium during hospice and palliative care. The gel’s name comes from the API brands that are used in it — lorazepam (Ativan^®), diphenhydramine (Benadryl^®) and haloperidol (Haldol^®).

Lorazepam is a short-acting benzodiazepine used in patients with anxiety, shortness of breath and nausea. It acts on postsynaptic GABA receptors — a type of receptor in the brain that responds to the neurotransmitter gamma-aminobutyric acid (GABA) — located in multiple sites within the central nervous system (CNS). Sedation and confusion are common side effects.

Diphenhydramine is a first-generation antihistamine that acts on the histamine-1 (H-1) receptor. It is used for sedation, nausea and the extrapyramidal effects — the involuntary movement disorders such as tardive dyskinesia — of dopamine antagonists. Considered an anticholinergic medication, it causes a variety of side effects, including drowsiness, constipation, confusion, dry mouth, agitation, anxiety and urinary retention.

Haloperidol is a first-generation antipsychotic that acts primarily by inhibiting the D2 dopaminergic receptor — a protein that plays a key role in many brain functions. The API is used to sedate and calm patients. It carries an increased risk of extrapyramidal side effects, and oral haloperidol has a higher risk of delirium and mortality in palliative care patients.³

As a topical application, ABH gel is typically administered on the wrist, rubbed behind the ears or on the bottom of the feet.

Since ABH gel is not commercially available, compounding pharmacies may compound ABH preparations tailored to meet the unique needs of individual patients. The formulation should use a base vehicle that is smooth to the touch and that delivers exceptional API permeation through various levels of the skin.

Studied Results: PermE8^® Anhydrous Gel

PermE8 Anhydrous Gel ticks all of these boxes. Not only does it feature a silky texture that spreads quickly compared to other topical preparations, but it also can hold multiple APIs — including salt forms — in one compounded preparation. And due to water activity (Aw) of less than 0.6 (<.6), PermE8 offers the potential for longer beyond-use dates (BUDs).* Extended BUDs benefit not only compounding pharmacies by helping to lower operating costs but also hospice providers and caretakers due to fewer pharmacy refills.⁴

The need to deliver exceptional API permeation through various levels of the skin was supported in an independent study that compared the percutaneous absorption of ketoprofen in a formulation using PermE8 Anhydrous Gel to a formulation using PCCA Lipoderm®. Results indicated no significant difference between the two formulations (see Figure 1). Researchers concluded that the extent and rate of absorption in the PermE8 formulation is comparable to the industry-leading, permeation-enhancing Lipoderm.⁴

Figure 1
Across donor summary: the mean percutaneous absorption and distribution of ketoprofen in two compounded formulas after 48 hours diffusion.

PCCA members with clinical services access may view and/or download PCCA formulations to compound ABH gel preparations after logging on to our Members-Only Website. Clinical services access also allows members to contact our Clinical Services team for additional information on compounding ABH gel, hospice and palliative care or other compounding concerns. Members without clinical services access can learn how to connect with the experts on our Clinical Services team HERE.

PCCA is recognized as the leader of quality products, education and advocacy in the compounding industry. Find out how a PCCA membership can benefit your compounding practice.

*USP 795 establishes BUD limits by type of preparation in the absence of a USP−NF Compounded Preparation Monograph or CNSP-specific stability information.

References

1. Blaszczyk AT, Bailey TA, Tapia S. ABH Gel: Comforting Cure or Pricey Placebo?. J Am Med Dir Assoc. 2021;22(1):23-27. Accessed December 2024 at https://pubmed.ncbi.nlm.nih.gov/33246839/
2. Moon RB. ABHR Gel in the Treatment of Nausea and Vomiting in the Hospice Patient. Int J Pharm Compd. 2006;10(2):95-98. Abstract accessed December 2024 at https://pubmed.ncbi.nlm.nih.gov/23974181/
3. Dahal A, Neupane R, Boddu SH, et al. Percutaneous Absorption of Lorazepam, Diphenhydramine Hydrochloride, and Haloperidol from ABH Gel. Int J Pharm Compd. 2020;24(2):168-175. Abstract accessed December 2024 at https://pubmed.ncbi.nlm.nih.gov/32196480/
4. PCCA Science. PCCA PermE8™ Anhydrous Ge Product Information Sheet. Document number 99608; 2018. Accessed December 2024 at PCCA Members-Only Website
5. PCCA Science. (2018) PermE8/Lipoderm Technical Report: Evaluation of the in vitro Human Skin Percutaneous Absorption of Ketoprofen in PCCA PermE8 Anhydrous Gel vs. PCCA Lipoderm . Document number 99732. Accessed December 2024 at PCCA Members-Only Website.

These statements are provided for educational purposes only. They have not been evaluated by the Food and Drug Administration, and are not to be interpreted as a promise, guarantee or claim of therapeutic efficacy or safety. The information contained herein is not intended to replace or substitute for conventional medical care or encourage its abandonment.