Recipe - Compounding Worksheet
Unauthorized distribution, copying or disclosure prohibited.
These recipes are intended for use by the pharmacy manufacturing departments only.
LET Topical Gel (Prince George Hospital recipe)    Lidocaine 4%-Epinephrine 0.05%-Tetracaine 0.5%
Lot No Expiry(mm/yyyy) Ingredients Master Formula
    lidocaine HCl USP    PWD   
    tetracaine HCl   PWD   
    epinephrine  1mg/mL  INJ   
    Methylcellulose   1500 mPA-s  PWD   
    sodium chloride (bacteriostatic)  0.9%  INJ  qs to  
Recipe Total Quantity:
Final Quantity Desired: mL

Directions: 1. Measure out lidocaine and tetracaine powder; combine in a mortar.
2. Add epinephrine to powder mixture and pour into a graduated cylinder.
3. QS to required amount with bacteriostatic sodium chloride.
4. Measure out required methylcellulose in a mortar.
5. Slowly add small amounts (less than 15 mL at a time) of prepared lidocaine, epinephrine, tetracaine (LET) solution to the methylcellulose powder.
6. Allow methylcellulose to hydrate; if LET is added too quickly, it will not gel properly. LET should be mixed with methylcellulose powder well enough to form a clear gel before 30 mL of LET has been added.
7. Continue to add LET solution slowly and allow the gel to hydrate to a clear smooth gel.
8. Transfer into final container(s) and label.

Notes As of January 2020, AHS standardized outsourcing of LET Gel to Gentes & Bolduc Compounding Services. In house compounding should be reserved for shortage/backorder scenarios only.

Decant gel mixture into 15 gram ointment pots. Recipe makes 10 x 15 mL.

Since there is no stability data available, assign beyond use date using NAPRA Guidance Document For Pharmacy Compounding Of Non-Sterile Preparations:
Water-containing topical/dermal, mucosal liquid and semi-solid formulations The BUD is not later than 30 days. Note: used 30 days refrigerated rather than arbitrary NAPRA BUD.

THIS FORMULATION IS NOT BASED ON LITERATURE, but is from unpublished data, historical use or physician/pharmacy experience.

Packaging:  Ointment Jar

Auxiliary Labels: For External Use Only
  Refrigerate

Storage/Expiry:Refrigerator: 30 days

Last Date Revised: 9-Nov-21

References:Prince George Regional Hospital - Vancouver Island Health Authority - South.
 
National Association of Pharmacy Regulatory Authorities (NAPRA). Guidance Document For Pharmacy Compounding Of Non-Sterile Preparations. Ottawa, ON: National Association of Pharmacy Regulatory Authorities (NAPRA); 2018.
Available at: https://napra.ca/sites/default/files/documents/Mdl_Stnds_Pharmacy_Compounding_Nonsterile_Preparations_Guidance_June2018_FINAL.pdf

Completed Compound Check
Lot NoDate Prepared Expiry DateTechnicianPharmacist
   6-Dec-2021         


This content is provided for general information purposes only. It is not intended to replace consultations with a health care professional or to provide medical advice, diagnosis or treatment. Always seek the advice of a physician or other qualified health care provider with any medical or health questions. Alberta Health Services accepts no responsibility for any modification or redistribution of this document and is not liable for any actions taken by individuals based on the information provided, or for any inaccuracies, errors, or omissions in the information in this document. These recipes are to be used as a reference and are not intended to be master formulation records. Not all recipes may be compliant with NAPRA or other standards.