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April 5, 2012 - Oral Meds and the Eye
1. 4/10/2012
Optometrists need to recognize ourselves as
primary care health providers
Oral meds are under utilized by doctors for eye
conditions
This lecture should instill confidence in us to
prescribe in the best interests of our patients
Jill Autry, OD, RPh
SPECIAL THANKS TO JILL AUTRY OD RPh Eye Center of Texas, Houston
from the Eye Center of Texas drjillautry@tropicalce.com
Optometric Glaucoma Specialist
One 10-day supply of oral antibiotics Internal/External hordeola
One 72-hour supply of oral antihistamines Preseptal cellulitis
Dacryocystitis
One 7-day supply of oral NSAIDs
Dacryoadenitis
One 3-day supply of analgesics in
Canaliculitis
Schedules III, IV, and V
Chlamydia
Antiglaucoma drugs
Dry eye/posterior blepharitis/ocular rosacea
Appropriate medications to treat anaphylaxis
1
3. 4/10/2012
Penicillin antibiotic (aminopenicillin)
Extended coverage over standard PCN
Good for staph infections because resistant
to beta lactamases
Also has some gram negative coverage
Gram negative resistance increasing
Inexpensive
3
4. 4/10/2012
Skin and soft tissue infections
Adults
875mg q12h
Children
20-40mg/kg/day divided q8h
Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D.
Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D.
6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy
Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478
Phone (713)797-1010 Phone (281)998-3333 (281)277-1010 Augmentin = Amoxicillin + Clavulanic acid
450 Medical Ctr Blvd, #305
Webster, TX 77598
11914 Astoria Boulevard, #325
Houston, TX 77089
21700 Kingsland Blvd.
Katy, TX 77450
Cannot use if penicillin allergic
(281) 332-1397 (281) 484-2030 (281) 578-4815
Clavulanic acid is a “suicide inhibitor”
Protects amoxicillin from beta-lactamases
NAME Jack Cooper AGE ________
Does not have antibiotic action itself
ADDRESS_____________________________________________________DATE 3-3-12 Allows increased coverage with less
destruction by beta-lactamases
Rx Amoxicillin 875mg
1 po bid x 10 days #20 Also covers anaerobes
Good for human and animal bites
REFILLS-- 0 Jill Autry, O.D.
4
5. 4/10/2012
Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D.
Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D.
6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy
Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478
Phone (713)797-1010 Phone (281)998-3333 (281)277-1010
Can use in pregnancy (category B) 450 Medical Ctr Blvd, #305
Webster, TX 77598
11914 Astoria Boulevard, #325
Houston, TX 77089
21700 Kingsland Blvd.
Katy, TX 77450
Can use in children (281) 332-1397 (281) 484-2030 (281) 578-4815
Can cause nausea/vomiting/diarrhea NAME Jack Cooper AGE ________
Take with food/yogurt
ADDRESS_____________________________________________________DATE 3-3-12
Few drug interactions
Allopurinol/probenecid (both for gout) Rx Augmentin 875mg
1 po bid x 10 days #20
875mg bid
Generic available but still expensive ($60.54)
REFILLS-- 0 Jill Autry, O.D.
Small percentage of patients will also be Beta-lactam antibiotic class
allergic to cephalosporins Increased coverage over penicillin class
Literature suggests anywhere from 3-10% 3-10% cross-sensitivity to penicillin class in
cross-sensitivity regards to allergic reactions
Could use a –mycin, –cycline, -quinolone Four generations of cephalosporins
Could use Septra if not sulfa allergic Increasing gram negative activity from 1 to 4
First and second generations better for ocular
conditions (more likely gram positive)
5
6. 4/10/2012
82% of patients who report a PCN allergy do
not react to skin testing
Risk is much lower with second (0.2%) and
third (0.2%) gen vs. first gen (0.5%)
American Academy of Pediatrics ok with
certain meds even in the face of PCN allergy as
long as not severe, i.e. anaphylaxis
Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D.
Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D.
6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy
Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478
Phone (713)797-1010 Phone (281)998-3333 (281)277-1010
According to the Academy of Pediatrics… 450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd.
If allergic to PCN… Webster, TX 77598
(281) 332-1397
Houston, TX 77089
(281) 484-2030
Katy, TX 77450
(281) 578-4815
OK to use cefdinir (Omnicef™) or
cefuroxime(Ceftin™) if: NAME Jack Cooper AGE ________
No history of cephalosporin allergy ADDRESS_____________________________________________________DATE 3-3-12
No history of multiple other allergic reactions
Rx Ceftin 500mg #14
No history of atopic conditions
1 po bid UAT
No history of severe allergic reaction
REFILLS-- 0 Jill Autry, O.D.
6
7. 4/10/2012
Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D.
Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D.
6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy
Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478
Phone (713)797-1010 Phone (281)998-3333 (281)277-1010
450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Inhibit bacterial protein synthesis
Webster, TX 77598 Houston, TX 77089 Katy, TX 77450
(281) 332-1397 (281) 484-2030 (281) 578-4815 Erythromycin, clarithromycin, azithromycin
Use with caution in liver disease
NAME Jack Cooper AGE ________
Drug interactions increased
ADDRESS_____________________________________________________DATE 3-3-12 Great for penicillin allergic patients
Rx Omnicef 300mg #14
1 po bid UAT
REFILLS-- 0 Jill Autry, O.D.
Macrolide antibiotic Z-pack
Dosing regimen increases compliance 500mg day one; 250mg days 2-5
OK in pregnancy and children Great for compliance
For milder infections
Less GI effects than erythromycin
Less drug interactions than other macrolides Treatment of chlamydia with 1 g dose
Prescribe four 250mg tablets
Drug of choice for chlamydial conjunctivitis
Take all at once
7
8. 4/10/2012
Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D.
Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D. Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D.
6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy 6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy
Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478 Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478
Phone (713)797-1010 Phone (281)998-3333 (281)277-1010 Phone (713)797-1010 Phone (281)998-3333 (281)277-1010
450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. 450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd.
Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 Webster, TX 77598 Houston, TX 77089 Katy, TX 77450
(281) 332-1397 (281) 484-2030 (281) 578-4815 (281) 332-1397 (281) 484-2030 (281) 578-4815
NAME Jack Cooper AGE ________ NAME Jack Cooper AGE ________
ADDRESS_____________________________________________________DATE 3-3-12 ADDRESS_____________________________________________________DATE 3-3-12
Rx Zpak Rx Zithromax 250mg #4
Take 4 pills all at once
REFILLS-- 0 Jill Autry, O.D.
REFILLS-- 0 Jill Autry, O.D.
Sulfamethoxazole/Trimethoprim Sulfa allergy not sulfur allergy
Septra DS, Bactrim DS Rash is common sign; usually seen in the
Can use in PCN allergic patients antibiotic class of sulfonamides (like Septra®
or sulfacetamide ointment)
CANNOT use if Sulfa allergic
Less likely to see in non-antibiotic meds
Great gram positive and gram negative
Diamox®, Neptazane®, Azopt®, Trusopt®,
coverage
Cosopt®
Covers MRSA Even less likely to see with topical
Consider if cellulitis plus abscess and severe pain medications
Sulfites and sulfates are chemically different-
no cross reactivity with sulfa allergies
8
9. 4/10/2012
Inhibits bacterial protein synthesis
Tetracycline, Doxycyline, Minocycline Good broad spectrum activity
Cannot use in children younger than 8 qd to bid dosing
Cannot use in pregnancy/nursing Can take with food
Causes photosensitivity and photophobia Can take with dairy products
Long-term therapy associated with Cannot take with antacids
pseudotumor cerebri (rare) Cannot take before lying down
Minocycline more than other forms Must wait 2 hours
Esophageal ulceration
Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D.
Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D.
6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy
Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478
Phone (713)797-1010 Phone (281)998-3333 (281)277-1010
450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd.
Webster, TX 77598
(281) 332-1397
Houston, TX 77089
(281) 484-2030
Katy, TX 77450
(281) 578-4815
Antibiotic use
100mg bid x 10 days
NAME Jack Cooper AGE ________ Posterior blepharitis and Dry eye
50mg bid x 4-6 weeks then
ADDRESS_____________________________________________________DATE 3-3-12
50mg qd x 3-6 months or indefinitely
Rx Doxycycline 100mg Dermatologist to prescribe
1 po bid #20
Take with food
REFILLS-- 0 Jill Autry, O.D.
9
10. 4/10/2012
Cannot use in patients less than 18 years
Ciprofloxacin (CIPRO®) is prototype old
May decrease cartilage and bone formation
Blocks bacterial DNA synthesis
Heavily prescribed for urinary tract Cannot use in pregnancy/nursing
infections Cannot use in renal disease
Overprescribed in the 1990s Multiple drug and vitamin interactions
Little staph coverage now Musculoskeletal side effects
Mainly used for gram negative urinary tract Arthralgia, tendonitis, tendon rupture
infections
A fluoroquinolone
Can be used for patients allergic to PCN None are controlled substances
and/or cephalosporin Little to no abuse potential
OK for hordeolum/preseptal cellulitis Many available in OTC strength
Has some coverage against MRSA Patients vary in response to various products
NSAID ACTIONS
500mg qd x 7-10 days Inhibit cyclo-oxygenase pathway
No in children/pregnancy/breast feeding Results in decreased prostaglandin formation
Reduces pain
Reduces inflammation
Reduces edema
10
11. 4/10/2012
OTC
Ibuprofen 200mg
Schedule III and IV analgesics
Motrin®, Advil®, Nuprin® Non-scheduled pain meds
Naproxen 200mg
Alleve® Corneal abrasions, post-op PRK, post-op
Rx pterygium surgery, etc.
Ibuprofen 400mg, 600mg, 800mg
Naproxen (Naprosyn®)
Do not use in infectious processes, will mask
Ketorolac (Toradol®) 10mg pain of worsening infection
Celebrex® 100mg, 200mg
Others
Short term therapy only recommended
Need DEA # to prescribe scheduled meds
11
12. 4/10/2012
Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D.
Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D.
6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy
Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478
Phone (713)797-1010 Phone (281)998-3333 (281)277-1010
450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd.
Schedule III Webster, TX 77598 Houston, TX 77089 Katy, TX 77450
(281) 332-1397 (281) 484-2030 (281) 578-4815
Central acting narcotic analgesic
325mg acetaminophen + 30mg codeine NAME Jack Cooper AGE ________
Tylenol with codeine® elixir is APAP
120mg/5cc with 12mg codeine/5cc ADDRESS 6565 Golden River Drive, Houston, TX 77082 DATE 3-3-11
Avoid in liver/renal disease/alcoholism Rx Tylenol #3 #20 (twenty)
No extra Tylenol® in addition 1-2 po q4-6h prn pain
No alcohol
GI distress and sedation are main side effects
REFILLS-- zero Jill Autry, O.D.
MA0123456
12
13. 4/10/2012
Most codeine “allergies” are GI side effects or Significantly more pain relief and duration
of action compared to codeine
codeine initiated histamine release More addictive
“Stomach upset” Vicodin® (APAP w/hydrocodone)
Flushing 500mg APAP + 5mg hydrocodone
Itching Schedule III
True IgE mediated allergic reaction low Vicodin® ES (APAP w/hydrocodone)
750mg APAP + 7.5mg hydrocodone
Can use hydrocodone because it is a semi- Schedule III
synthetic form of codeine Vicoprofen®
200mg ibuprofen + 7.5mg hydrocodone
When Tylenol® is contraindicated/liver disease
Schedule III
Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D.
Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D.
6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy
Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478
Phone (713)797-1010 Phone (281)998-3333 (281)277-1010
450 Medical Ctr Blvd, #305
Webster, TX 77598
11914 Astoria Boulevard, #325
Houston, TX 77089
21700 Kingsland Blvd.
Katy, TX 77450
Nonbacteriostatic sulfonamide
(281) 332-1397 (281) 484-2030 (281) 578-4815
Decreases carbonic anhydrase
Decreases hydrogen and bicarb ion formation
NAME Jack Cooper AGE ________
Results in decreased aqueous production in
ADDRESS 6565 Golden River Drive, Houston, TX 77082 DATE 3-3-12 the ciliary body
Rx Vicodin 5/500 #20 (twenty)
Results in alkaline diuresis in the kidney but
1-2 po q4-6h prn pain
tolerance develops quickly
Contraindicated in renal, hepatic, or
respiratory disease
REFILLS-- zero Jill Autry, O.D.
MA0123456
13
14. 4/10/2012
Treatment of acute angle closure glaucoma
Treatment of less acute increased IOP
Treatment of post-surgical IOP spikes
Treatment of pseudotumor cerebri
Controversial treatment of serous retinal
detachments
Also used to prevent “altitude sickness”
Decreases carbonic anhydrase in the ciliary body
which decreases aqueous humor formation
Decreases IOP by 40-60%
Starts to work in 1 hour, peak effect at 4 hours
Comes in 125mg, 250mg, 500mg sequels
Angle closure dose: (2) 250mg tablets initially—
needs PI
14
15. 4/10/2012
Severe symptoms
Swelling of lips, tongue, throat
Difficulty breathing or swallowing
Call 911
Epi-pen if available
For treatment of anaphylactic reactions
Direct someone to call 911
Subcutaneous auto-injector
Works immediately but lasts only 10-15
minutes
Can write a prescription to keep in office
But only 18 month shelf life
15
16. 4/10/2012
1. PULL OFF GREY CAP
Found in tears
Can use for epithelial disease if patient can’t
2. HOLD FLUSH TO MID-THIGH.
use Viroptic®/Zirgan® secondary to
toxicity/severe dry eye/availability
Does not help in the treatment of stromal
3. PRESS HARD; WILL HEAR CLICK.
disease
Treat stromal disease with topical steroid
4. LEAVE FOR 10-15 SECONDS. Cover steroid with Viroptic®/Zirgan® or
oral antiviral
Herpes simplex keratitis
For Herpes Zoster (shingles) treatment
In place of topical treatment
For Bell’s Palsy treatment Acyclovir 400mg 5x day x 10 days
Must start within 72 hrs for best effect; Famvir® 250mg tid x 7 days
preferably within 24 hrs Valtrex® 500mg tid x 7 days
Acyclovir 800mg 5X day For prevention of recurrences
Acyclovir 400mg qd-bid
Famvir 500mg tid
Famvir® 250mg qd
Valtrex 1 gram tid Valtrex® 500 qd
16
17. 4/10/2012
Allergic reaction
Anterior uveitis
Posterior uveitis
Scleritis
Arteritic ischemic optic neuropathy
“Giant Cell”
Optic neuritis
Orbital pseudotumor
Herpes zoster
Other optic neuropathies
Increased intraocular pressure
Topical will increase in 2-4 weeks
Oral/IV can increase within 3-4 days
Cataract
Usually posterior subcapsular/ seen with oral steroids
Steroid induced diabetes/decrease control
Osteoporosis
Gastrointestinal ulceration
Adrenal suppression
Reduced immunity/infections
Mood swings/erratic behavior
17
18. 4/10/2012
Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D.
Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D.
6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy
Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478
Phone (713)797-1010 Phone (281)998-3333 (281)277-1010
Take with food or milk
Generally start 60-80 mg/day
450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd.
Webster, TX 77598 Houston, TX 77089 Katy, TX 77450
For posterior uveitis, Giant cell, after IV steroids (281) 332-1397 (281) 484-2030 (281) 578-4815
for optic neuritis, pseudotumor, scleritis
Must taper dosage over 1-2 weeks depending on
response NAME Joe Johnson AGE ______________
40-60 mg x 2-3 days does not need taper
ADDRESS_____________________________________________________DATE 3-3-12
Otherwise taper by 20% every few days unless on
steroids for months (then taper more slowly)
Rx Prednisone 20mg #30
Consider Medrol Dosepak 3 tabs (60mg) qd with food/milk
For allergic reactions, zoster, anterior uveitis
Less serious inflammations
REFILLS-- 0 _____________
Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D.
Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D.
6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy
Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478
Phone (713)797-1010 Phone (281)998-3333 (281)277-1010
450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd.
Webster, TX 77598 Houston, TX 77089 Katy, TX 77450
(281) 332-1397 (281) 484-2030 (281) 578-4815
NAME Joe Johnson AGE ______________
ADDRESS_____________________________________________________DATE 3-3-11
Rx Medrol Dose Pack
TUD
REFILLS-- 0 _____________
18
19. 4/10/2012
Tamoxifen
Most commonly after one year of therapy
Macular refractile bodies and RPE changes
Does not warrant discontinuation
Stop med if color vision decreases or CME
develops
Up to 6-8 diopters of acute myopia
Most cases within one month initiation
Choroidal effusion and ciliary body edema
Can lead to anterior displacement of lens and acute
angle closure with increased IOP
Not related to pupillary block
Not relieved by peripheral iridotomy (PI)
19
20. 4/10/2012
Increased risk of retinopathy:
Patients should discontinue the medication > 5 years use
as quickly as possible Cumulative dose > 1000 g
Must be tapered-cannot stop abruptly Daily dose > 400 mg/day
Hyperosmotic therapy Elderly
Kidney or liver disease
Cycloplegic
Concurrent retinal/macular disease
Topical antiglaucoma agents
Reported more with hyperopes
20
21. 4/10/2012
Revised recommendations on screening for
chloroquine and hydroxychloroquine
retinopathy
Ophthalmology. 2011 Feb;118(2):415-22
Screening:
10-2 VF (white-on-white)
Repeat promptly if changes
Fundus examination
Fundus photography
Not for screening; may be useful for documentation
No longer: Amsler grid, color vision, FA, etc.
http://www.alberta-
retina.com/Alberta%20Retina%20Consultants/Patient%20Info/Eye%20Diseases/Images/Plaq%20toxicity.jpg
Baseline examination
Within 1st year of therapy Optic neuropathy
Counsel patient about risk
Optic neuropathy secondary to decreased
Annual screening
axoplasmic flow
MINIMAL guidelines
Begin immediately if high risk Resulting optic nerve edema
Begin after 5 years of use Seen within weeks of initiation of drug
All patients
Visual acuity less affected than AION
If toxicity
Consider discontinuing medication Discontinue use
Slow clearing Disc edema will resolve over months
Visual function may continue to deteriorate
21
22. 4/10/2012
See the TOA Website for more
details about any of
our programs and issues
http:/texas.aoa.org
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