#compounding

USNS Mercy (T-AH 19) Pharmacy Side-by-Side with the Solomon Islands National Pharmacy Services Division

I finished The Alloy of Law right before the end of 2023!! I had an absolute blast with it!! Wax, Wayne and Marasi were a rusting hoot together! Wax’s deductions of the Vanishers’ crimes were some of my favorite parts of the book. Marasi’s criminal theories and growing friendship with Wax and Wayne were very entertaining. Wayne is EASILY the funniest Cosmere character so far. Wayne has too many lines of comedy gold. I knew I’d love him after “tea’s poisoned.”

I thought each of the three MCs had a surprising amount of depth. Marasi grew a surprising amount in such a short number of chapters. I was flabbergasted that her cadmium power saved the day. Wayne’s backstory of killing a father kinda tugged on my heart. I think Wax’s ongoing trauma over killing Lessie was a nice touch, and I hope Sanderson doesn’t sideline it.

I loved Miles both as an antagonist and a character. As an antagonist, he was very competent with a horrifying power. Ever since watching Hellsing Ultimate I realized the horror of regenerators. They’ll just keep coming back from any wound, and their healing looks disgusting at certain points. Miles’ power did not disappoint. He was a Pewterarm without being a Pewterarm. And as a character, I really like him. His frustration with the justice system is very relatable. He felt his actions weren’t helping people, as if he was stuck in a cycle. His dislike of Elendel feels like something you’d see in our world - a prominent city believed to be manipulating a poorer city. I wish he survived the book’s events.

The advancements of Allomancy and technology took this book to a new level. Whether it’s Wax’s Twinborn combo or Miles’ Compounding, gunplay interwining with Steelpushing, aluminum’s negation of magic, or Ranette’s Ironpulling interacting with the tech of her home. I never knew magic could combine so well with tech and guns. I was flabbergasted at the ridiculous limits of Wax’s Steelpushing, astounded by Miles’ healing output and the ridiculous number of embedded gold, and amazed by Wayne stealing DIO’s whole rusting flow. Tbh I’m still in awe from Wax and Wayne killing like 30 Vanishers, and the train fight, and Wayne having whole conversations in the time it takes to utter a single word. It’s even crazier that these are feats done with less raw power than Vin, Kelsier, and especially the Lord Ruler. No wonder both gods wanted the Lord Ruler to die.

Sueanoi here,

For seizure control by medicine injection, we have diazepam available. It's not the same, but the intended result of reducing anxiety and seizure control works.

Gabapentin has an additional effect of nerve-related analgesia, while at hospital, if the animal is resistant to pilling to the point that it's distressful, I'd prescribe another injection analgesia, or even fentanyl patch if needed.

The downside is, pills are often the cheapest form of medications available in the market. Using injections long term can accumulate cost to hazardous levels to the owner's wallet. (With well communication, this can still be a choice available if the owner is willing to pay)

Also, if animals are well familiarized with pilling, it is often the LESS stressful method of medication, comparing to getting restrained and injected with needles twice a day. (So please, owners, train your pets to take pills early in life.)

gettingvetted here.

Sueanoi practices in Asia, so I wanted to give a North American perspective here.

Transdermal formulations of pretty much anything is available these days. Find the right compounding pharmacy (typically Wedgewood or Roadrunner, but there are plenty of others including human pharmacies) and they can make you just about anything in transdermal form.

Here’s the issue - FDA approval of 99.9% of drugs (and 99.9% of studies surrounding drugs) is either for oral or injectable forms. There is no guarantee that transdermal formulations work in the same way as the drug’s other forms (or any guarantee that they work at all).

Plus, there is a veeeeery gray area surrounding compounded drugs (those that are taken from their original form and turned into another form, like an oral capsule/tablet into a liquid or transdermal), at least in the US: - Technically speaking, I am allowed to compound a drug for a patient if its approved form is unsuitable for the patient (for example, the only doses available are too large or the approved drug is mixed with another drug that I don’t want to use on the patient, like codiene with tylenol). - It is illegal to compound a drug for price purposes, for instance. - It is *technically* illegal to compound a drug if there is anything else that’s approved for the desired use and we haven’t tried that yet. For example if I want sedation for a vet visit in a cat, and the owner has tried but can’t give gabapentin capsules, I am technically supposed to have them try giving acepromazine, trazodone, etc prior to compounding gabapentin into a liquid or transdermal for the owner. - It is also illegal to compound drugs in bulk to keep in the hospital and then dispense individual doses of said compounded drugs to patients. So in a case like an ER, it would be illegal to order a bunch of transdermal gabapentin and trazodone to have on hand for individual patients. Each compounded drug is supposed to be used on one patient and one patient alone.

Those last two items are pretty much ignored by everyone... nobody is going to make a cat owner with difficulty pilling their cat, try acepromazine or trazodone pills prior to just prescribing them the gabapentin in an easier formulation. And pretty much every hospital has *something* sitting around that is compounded in bulk and dispensed in individual doses to patients (for example my hospital keeps compounded ponazuril and pimobendan in stock). Even the FDA has come out and said “listen we are just trying to keep randos from compounding and illegally selling potentially dangerous formulations of different medications, we’re not going to come after you for prescribing liquid gabapentin or keeping a stock of compounded dewormer in your hospital.”

Here’s a picture of my first time compounding an ointment. I’m glad I got to experience this but still very sad that the actual compounding final got put online, and I never got to make a gel.

I know we are all dealing with changes during these times, but it sucks doing some of these important things online. I’m worried that when I’m actually out working I won’t be able to do some things properly.