On Compounding Therapies
Examination Series: 01
Happy Monday. This marks the first week of an examination series starting with Compounding Therapies. For our purposes we’ll just refer to them as CTs so I’m not constantly typing it out.
This allows me to explore topics I’m interested in while hopefully providing value to you. The goal is not to make recommendations on things you should use. As you’ll see, CTs can just be slightly modified traditional prescriptions in the form of topical applications, injectables, or oral medications. Obviously, that comes with it strict adherence to the prescription from a DOCTOR. Not AG. The goal however, is to just open my own mind to on-going work in the world of pharmacology. And as the subtitle reads, an examination.
But first, let’s back up.
Pharmaceutical compounding has a long history dating back to the origins of pharmacy itself.
Compounding was the primary method of producing medications until the early 20th century. Before the advent of large-scale pharmaceutical manufacturing, pharmacists routinely combined, mixed, or altered ingredients to create customized medicines based on individual patient needs. And that brings us to what exactly are CTs?
What Are Compounding Therapies?
Compounding therapies are simply custom-made medications or treatments. Unlike the standard prescription meds you’d pick up from a pharmacy, these are specifically crafted to meet an individual’s unique needs. It’s like tailoring a suit - sure - off the rack works fine for most, but when you’re buying for your wedding, you need something that fits perfectly. Whether it’s altering the dosage, changing the form of the medication (like from a pill to a cream), or combining multiple ingredients into one solution, compounding gives us that flexibility.
What’s interesting is the recent growth of CTs.
While industrial drug production largely replaced traditional compounding for many decades, there has been a resurgence of interest in compounded medications in recent years. Several factors are driving this growth:
Personalized Medicine: The increasing demand for personalized medical care has catalyzed a resurgence in compounding.
Filling Gaps: Compounding can address therapeutic needs not met by commercially available FDA-approved drugs. This includes:
Creating alternate dosage strengths or forms
Omitting allergens or problematic ingredients
Addressing drug shortages or discontinuations
Specific Patient Populations: Compounding benefits groups like pediatric patients, people with difficulty swallowing pills, and those with rare conditions lacking FDA-approved treatments.
Expanding Applications: Compounded drugs are now used across a wide spectrum of therapeutic areas, including men's and women's health, pain management, sports medicine, and various medical specialties.
Economic Factors: For some pharmacies, compounding has become a significant revenue source, especially as traditional prescription sales have declined.
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More specifically, compounding has gained particular attention recently due to shortages of popular weight loss drugs. Some doctors are using compounded versions of medications like semaglutide and tirzepatide when brand-name versions are unavailable. While compounding offers valuable therapeutic options, it's important to note that compounded medications do not undergo the same FDA approval process as commercially manufactured drugs.
How Do They Work?
CTs are created by trained pharmacists who mix, adjust, and combine ingredients based on a doctor’s prescription. Athletes might need a specific formulation of a recovery medication, for instance, that is free from substances on the banned list or easier to absorb after a workout. The pharmacist ensures that the final product is safe, effective, and uniquely suited to that individual’s needs.
For example, a high-performing athlete could have a sensitivity to standard anti-inflammatory medications. A compounded cream can be created to bypass the digestive system and minimize the risk of side effects, while delivering targeted relief to an injured area.
Of course, modifying an existing medication brings risk with it. You could argue that not modifying it also carries risk as well. Have you ever read the list of side effects on a prescription you received? The argument of risk goes both ways. By not modifying, you’re going to use an FDA approved medication. But by modifying, although it’s not specifically approved by the FDA in that form, you’re getting the active ingredient(s) in the medication while staying away from potentially banned substances, substances you’re allergic to, or limiting adverse side effects by changing the form by which you ingest the medication - like switching from an injectable to an oral form.
Risks of Compounding Therapies
More specifically on risk: CTs come with their own set of risks. Since these are customized products, they don’t undergo the same large-scale testing that commercially available medications do. This means there's a higher reliance on the skill of the pharmacist and the accuracy of the prescribed formula. Any errors in preparation, dosage, or ingredient compatibility can lead to complications. That’s why it's crucial to work with trusted professionals and ensure that all safety standards are met. For athletes, there’s also the concern of running into anti-doping regulations, so rigorous testing and transparency are key.
So what are they actually used for? We already mentioned weight loss.
Most Common Forms of Compounding Therapies
In the world of elite performance, compounding therapies can come in several forms, each designed to support different aspects of health and performance:
Topical creams and gels: Popular for pain relief, muscle recovery, and treating inflammation. They allow the active ingredients to be absorbed directly through the skin, targeting specific areas.
Injectables: Some athletes might require vitamin injections or hormone therapies that are tailored to their specific performance or recovery needs. These are often used to optimize recovery and support energy levels.
Oral medications: Compounded capsules or tablets can be formulated with precise dosages or combinations of ingredients that wouldn’t be available in standard prescriptions.
Troches and lozenges: For athletes who need slow, steady absorption of a medication, these dissolvable treatments can be a convenient option.
There are also two other areas of major growth in CTs: bioidentical hormone replacement therapy (BHRT) and compounded peptide therapy.
Bioidentical Hormone Replacement Therapy (BHRT)
What is BHRT? Bioidentical hormone replacement therapy uses hormones that are chemically identical to those produced naturally by the human body. The idea behind BHRT is to restore hormonal balance in a way that’s more natural and effective compared to traditional hormone replacement therapy (HRT), which often uses synthetic or animal-derived hormones.
For athletes and high performers, hormonal balance is obviously critical for peak fitness, recovery, managing stress, and even longevity. Hormones like testosterone, estrogen, and progesterone play significant roles in muscle mass, fat metabolism, energy levels, and overall health. As these levels fluctuate—whether due to aging, stress, or other factors—performance and recovery can take a hit.
Why BHRT for Athletes?
At the elite level, even slight imbalances in hormone levels can impact performance. For example, low testosterone can lead to muscle weakness, fatigue, and poor recovery, while imbalances in estrogen levels (yes, even in men) can affect bone health and metabolism. BHRT aims to optimize these levels, helping athletes maintain their edge.
Here’s how BHRT can benefit athletes:
Improved recovery: Hormones are critical in muscle repair and recovery after intense training. Optimized levels of testosterone, for instance, can enhance protein synthesis, aiding in faster recovery.
Energy and endurance: Hormones like thyroid hormones influence metabolism and energy levels. By maintaining balance, athletes can sustain higher levels of energy and endurance throughout training and competition.
Mental clarity and focus: Hormones also play a role in cognitive function. BHRT can help athletes maintain mental sharpness and manage stress, particularly in high-pressure environments.
How BHRT is Compounded
Compounded BHRT medications are custom-made for each individual. A performance doctor will run detailed blood work and assess hormone levels, then prescribe specific doses of bioidentical hormones that are tailored to the athlete’s unique needs. These hormones can be delivered in various forms, such as creams, gels, injections, or capsules. The precision of compounding allows for fine-tuning that standard hormone treatments can't offer, ensuring athletes get the right balance without the risks of over- or under-dosing.
Compounded Peptide Therapy
What are Peptides? Peptides are short chains of amino acids that act as signaling molecules in the body. They help regulate various biological processes, including hormone production, tissue repair, immune function, and metabolism. Compounded peptide therapy involves creating tailored peptide formulations that support an athlete's specific goals, such as muscle recovery, fat loss, or even cognitive enhancement.
Peptide therapies have gained significant popularity in performance circles because they can be more targeted and potentially safer than some traditional performance-enhancing drugs. Since peptides are naturally occurring in the body, they often come with fewer side effects when compared to synthetic drugs. Have you ever wondered by it only took Aaron Rodgers 11 weeks to return to practice after tearing his achilles? Of course the Jets want to get a return on the $75M guaranteed to Rodgers, and we know he is also particularly health conscious when compared to other athletes in the NFL. And while he may not have used peptides in his recovery, there is an almost certainty they are used in the league for varying purposes.
Key Peptides in Performance Enhancement
BPC-157 (Body Protection Compound): One of the most common peptides in the performance world, BPC-157 is known for its ability to promote healing and repair damaged tissues. Athletes commonly use it to recover from injuries faster, whether it’s a torn muscle, tendon strain, or ligament injury.
Thymosin Beta-4: This peptide promotes wound healing and recovery from muscle damage. It’s particularly useful for athletes who experience overuse injuries or need to accelerate healing from surgery or injury.
CJC-1295/Ipamorelin: This peptide combination stimulates the release of growth hormone, which can aid in muscle growth, fat loss, and recovery. For athletes looking to boost their strength and endurance, CJC-1295 and Ipamorelin can enhance the body’s natural production of growth hormone in a more controlled way than synthetic growth hormone.
PT-141: While traditionally known for its use in sexual health, PT-141 is also being explored for its ability to improve stamina and energy in athletes. It acts on the nervous system and can boost motivation and endurance during training.
What’s especially interesting is even semaglutide (Wegovy, Ozempic, etc) and insulin are peptides. Specifically, semaglutide is a GLP-1 peptide that mimics the GLP-1 hormone in our bodies to control blood sugar and reduce appetite.
How Peptide Therapy Works
Peptides are usually delivered through subcutaneous injections, though some may also be compounded into creams, nasal sprays, or oral forms depending on the athlete’s preference and specific needs. The key to successful peptide therapy is customization—formulations are carefully adjusted based on the athlete's goals, be it muscle recovery, fat loss, or cognitive enhancement.
The Benefits of Peptide Therapy for Athletes
Faster recovery: Peptides like BPC-157 and Thymosin Beta-4 can drastically reduce recovery times from injuries, allowing athletes to get back to training and competition quicker.
Lean muscle growth: Peptides like CJC-1295 stimulate growth hormone release, which can lead to increased muscle mass and improved strength without the use of steroids or other banned substances.
Fat loss: Certain peptides help the body break down fat more efficiently while preserving muscle mass, which is particularly important in sports that require maintaining a specific weight category.
Anti-aging and longevity: We’re also seeing the use of peptides for “anti-aging benefits”. By optimizing growth hormone levels and promoting cellular repair, peptide therapy can help athletes maintain peak performance for longer.
The was a bit of an excursion into performance enhancement and recovery. To get back to the larger conversation, we’re seeing massive growth in the use of CTs for a WIDE range of reasons:
Increasing demand for personalized medicine: Patients are seeking more customized treatments tailored to their specific needs, which compounding pharmacies can provide.
Rising prevalence of chronic diseases: The growing incidence of chronic conditions globally is necessitating patient-specific solutions, driving demand for compounded medications.
This is particularly interesting if you read my most recent post addressing this very issue. Chronic diseases essentially make up the 4 Horsemen: Atherosclerotic disease (comprised of cardiovascular disease and cerebrovascular disease), Cancer, Neurodegenerative disease (most common being Alzheimer’s), and “Foundational disease” ⇒ a spectrum of everything hyperinsulinemia to insulin resistance to fatty liver disease to type 2 diabetes.
Aging population: Birth rates are down. Old people are up. The expanding geriatric demographic often requires specialized medications that may not be available in mass-produced formats.
Drug shortages: Compounding pharmacies are filling supply gaps caused by shortages of commercially available drugs. We’ve seen specific shortages in the GLP-1 market, but this of course can apply to literally any drug on the market.
Technological advancements: Innovations in compounding technologies are improving production efficiency, safety, and customization capabilities.
Regulatory support: Advancements in regulations are supporting the development and use of customized drug formulations.
Expanding applications: Growth in areas such as pain management, hormone replacement therapy, pediatric medicine, and oncology is driving demand for compounded medications.
Flexibility in addressing patient needs: Compounding pharmacies can provide solutions for patients with allergies, dosing requirements, or need for specific delivery methods not available in commercial products.
Advancements in pharmaceutical compounding: Improved techniques and equipment are enhancing the ability to create more precise and effective customized medications.
Shift towards patient-centric care: Healthcare systems are increasingly prioritizing personalized approaches to treatment, aligning with the offerings of compounding pharmacies.
As I mentioned in the beginning - this post is not to make a recommendation that you should use compounding therapies. But purely to open your eyes to the world of pharmacology. You may have been prescribed a CT without even knowing it in the past. There’s also been a massive growth of CT facilities for shipping these drugs to patients. This growth was tied to the growth of HRT clinics with minimal true primary care physician (PCP) oversight. Rather than get a prescription from your PCP who knows you best, many have just gone to clinics and hopped on testosterone without their prescriber knowing everything about them, a holistic view. And this ties back to risk. A world where your PCP can understand your health from a holistic lens, and make recommendations and prescriptions by using preventative measures, rather than just treating the symptoms, is a world I want to live in. That’s how we tackle the 4 Horsemen, and is the basis for Medicine 3.0 as outlined in Peter Attia’s incredible book Outlive.
I hope you enjoyed and Happy Monday.
Cheers.
DISCLAIMER
This is not Legal, Medical, or Financial advice. Please consult a medical professional before starting any workout program, diet plan, or supplement protocol.