Recipe - Compounding Worksheet
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These recipes are intended for use by the pharmacy manufacturing departments only.
Lidocaine Viscous 2%/ Antacid Liquid (Pink Lady) Mouthwash Suspension    1:1
Lot No Expiry(mm/yyyy) Ingredients Master Formula
    lidocaine viscous  2%  PO SOLN   
    aluminum hydroxide - magnesium hydroxide  40 mg - 40 mg/mL  SUSP  (Maalox, Almagel or equivalent) 
Recipe Total Quantity:
Final Quantity Desired: mL

Directions: 1. Measure out equal amounts of both ingredients.
2. Combine ingredients and mix well.
3. Transfer to final container and label.

Notes The ingredients can be mixed just prior to administration and used immediately.

Various other dilutions have been used.

Assign expiry date using USP 795 Guidelines, since no stability data available.
USP 795 guidelines - Water-Containing Formulations:
The beyond-use date is not later than 14 days for liquid preparations when stored at cold temperature between 2C - 8C.

THIS FORMULATION IS NOT BASED ON LITERATURE, but is from unpublished data, historical use or physician/pharmacy experience.

Packaging:  Amber Plastic Bottle

Auxiliary Labels: Refrigerate
  Shake Well

Storage/Expiry:Refrigerator: 14 days

Last Date Revised: 27-Apr-20

References:USP 34 NF 29, 2nd Volume 1. Chapter 795: Pharmaceutical compounding Nonsterile preparations. Rockville, MD, USA: United States Pharmacopeial Convention; 2010

Completed Compound Check
Lot NoDate Prepared Expiry DateTechnicianPharmacist

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