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Hey guys, I've been trying to post this in a Facebook group but it keeps getting auto-deleted so I've popped it here instead. I completed my compounding training last weekend and I promised I would share some things I learned that might be relevant for people who are tapering! Whether you are making your own doses at home or considering using a compounding pharmacy I have a few takeaways for you :)

(FYI I’m Alicia, a pharmacist from Canberra and founder of TaperMate - a mobile app and telehealth service to support people to safely taper off psychotropic medications).

1. I feel significantly more confident about how much more accurate compounding CAN be (compared to doing it yourself at home) if done by the right pharmacist who understands the importance of accuracy for medication tapering. While there is allowed to be a 10% +/- margin of error for measurements, good compounding pharmacies will use a maximum 2% margin for error (which is actually more accurate than some commercially available products). This is a question you could ask your compounding pharmacy - What is your allowable margin of error?

2. When it comes to asking your doctor for a prescription for compounding, it’s probably actually best to speak to the compounding pharmacy first. They can discuss your options and help you find the right strength/concentration to best balance accuracy with cost effectiveness. For example, you don’t want to be ordering 200mLs of liquid if it’s going to expire in 28 days and you’ll only get through 100mLs but you also don’t want to be needing to refill the script every week either. Or if you are getting capsules made, it is often cheaper to get them in batches of 100 (or whatever their capsuling machine is capable of making) so it will work out better for your doctor to write a quantity of 100 IF you will actually use them. With capsules you have the choice of getting the exact dose you need made up e.g if your dose is 18mg for this month they can give you 30x18mg capsules. OR you can get a few different strengths made e.g. 10mg, 5mg and 1mg capsules and make up your 18mg dose using these, and then also make your next reduction using them too. This method gives you more flexibility to adjust your dose if needed, but will have a higher upfront cost. 

3. Even scales that read to 0.001g can’t necessarily accurately measure something that small. You need to calculate the Minimum Accurate Weighable Quantity (MAWQ). E.g. Apparently the GEMINI 20 scale which a lot of people get from Amazon has a MAWQ of 0.005g (5mg). If the amount that is being weighed is smaller than that the margin for error starts to increase. Compounding pharmacies are using super accurate analytical scales and measuring the total weight for the batch (usually a month's supply) rather than a single dose, so this issue is less likely to come up. But if it does, they are able to add inert fillers to increase the powder weight and accurately measure tiny doses of active ingredient. They then have fancy capsuling machines which allow the total powder to be evenly mixed and spread between each capsule so the doses remain highly accurate. A way around this issue for people weighing doses at home would be to put something on the scale (e.g. a calibration weight or coin) and take note of the weight (do not tare the scale). Then weigh your dose and remember to subtract the weight of the item on the scale. This way you are measuring in the accurate window for the scale and will get more consistent results. 

4. Crushing tablets before mixing them with liquids to make a suspension is more important than I had previously thought. Generally tablets will break down in water and start dissolving/disintegrating but to make an accurate suspension it’s important that the particle sizes are similar. In saying that, making sure you don’t lose powder in the process of crushing is very important too. Whatever you use to crush your tablets should be easily rinsed with liquid into your jar so that you can capture the leftover powder stuck to the crusher. Crushing the tablet between two spoons is good as these can easily be rinsed. Remember you don’t want to add extra liquid to the mix either, so use part of your measured amount of liquid to do the rinsing. E.g. If you are mixing your tablet into 50mLs of water to make a suspension, keep aside 10mLs to rinse your crusher and capture the rinsed liquid in your jar/bottle. This way you know the exact strength of your liquid e.g. 50mg/50mL = 1mg/mL

5. If you are making a liquid, and just mixing your tablet into water we usually recommend not to keep any leftovers because we don’t have stability data for it. In saying that, if you keep it in a well-sealed container in the fridge it will probably be okay for up to 7 days according to the Australian Pharmaceutical Formulary 26 Expiry Date Decision Tree for pharmacists. But of course this depends on your specific medication’s stability in water and I would still err on the side of caution with this to make sure you get accurate doses and avoid microbial growth in your liquids. 

6. If you want to make more accurate suspensions and be able to keep your liquids for longer you can purchase a product called Ora-Plus, or Ora-Blend which is a pharmaceutical grade suspending agent used by compounding pharmacies to make suspensions. It’s suitable for most drugs (though it’s still best to check with your pharmacist if it’s compatible with your drug). It helps to keep the particles evenly suspended in the mixture and has an anti-foaming agent so that you can shake it vigorously without getting lots of air bubbles. It also has a preservative so you can keep suspensions made with this for 28 days in the fridge. Ora-Plus is a suspending agent, it should be mixed in a 50:50 ratio with water or a flavouring agent. Ora-Blend is a suspending agent mixed with a sweet flavouring and can be used as is (undiluted) to make suspensions. These products do cost upwards of $70 a bottle though so consider whether it's worth it and what concentration you want to make your suspension so that you get the most bang for your buck. 

7. I am very keen to get started with compounding and will be looking to start a service that will post all over Australia by the end of this year. We will make capsules and liquids and I’m also aiming to make “tapering strips” like those available overseas where a tapering protocol like the Maudsley Deprescribing Guidelines or RELEASE Toolkit can be made into easy to use monthly packs delivered to your door. I’m hoping this will get more doctors on board with hyperbolic tapering plans, as they will feel less worried about the logistics of how to actually get the small doses needed to follow these plans. I still need to figure out how these tapering strips can be adjusted if a dose reduction is too much and the person needs to updose but we will find ways around this I’m sure!

Let me know if you have other compounding questions and I’ll see if I can answer!