april 5, 2012 - oral meds and the eye

4/10/2012

1

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

SPECIAL THANKS TO JILL AUTRY OD RPhfrom the Eye Center of Texas

Jill Autry, OD, RPhEye Center of Texas, Houston

[email protected]

Optometric Glaucoma Specialist One 10-day supply of oral antibiotics One 72-hour supply of oral antihistamines One 7-day supply of oral NSAIDs One 3-day supply of analgesics in

Schedules III, IV, and V Antiglaucoma drugs Appropriate medications to treat anaphylaxis

Internal/External hordeola Preseptal cellulitis Dacryocystitis Dacryoadenitis Canaliculitis Chlamydia Dry eye/posterior blepharitis/ocular rosacea

4/10/2012

2

4/10/2012

3

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

4/10/2012

4

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 FrwyBellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478Phone (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 Jack Cooper AGE ________

ADDRESS_____________________________________________________DATE 3-3-12

Rx Amoxicillin 875mg1 po bid x 10 days #20

REFILLS-- 0 Jill Autry, O.D.

Augmentin = Amoxicillin + Clavulanic acid Cannot use if penicillin allergic Clavulanic acid is a “suicide inhibitor”

Protects amoxicillin from beta-lactamases Does not have antibiotic action itself

Allows increased coverage with less destruction by beta-lactamases

Also covers anaerobes Good for human and animal bites

4/10/2012

5

Can use in pregnancy (category B) Can use in children Can cause nausea/vomiting/diarrhea Take with food/yogurt Few drug interactions

Allopurinol/probenecid (both for gout)

875mg bid Generic available but still expensive ($60.54)





ADDRESS_____________________________________________________DATE 3-3-12

Rx Augmentin 875mg1 po bid x 10 days #20


Small percentage of patients will also be allergic to cephalosporins

Literature suggests anywhere from 3-10% cross-sensitivity

Could use a –mycin, –cycline, -quinolone Could use Septra if not sulfa allergic

Beta-lactam antibiotic class Increased coverage over penicillin class 3-10% cross-sensitivity to penicillin class in

regards to allergic reactions Four generations of cephalosporins

Increasing gram negative activity from 1 to 4 First and second generations better for ocular

conditions (more likely gram positive)

4/10/2012

6

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

According to the Academy of Pediatrics… If allergic to PCN… OK to use cefdinir (Omnicef™) or

cefuroxime(Ceftin™) if: No history of cephalosporin allergy No history of multiple other allergic reactions No history of atopic conditions No history of severe allergic reaction





ADDRESS_____________________________________________________DATE 3-3-12

Rx Ceftin 500mg #141 po bid UAT


4/10/2012

7





ADDRESS_____________________________________________________DATE 3-3-12

Rx Omnicef 300mg #141 po bid UAT


Inhibit bacterial protein synthesis Erythromycin, clarithromycin, azithromycin Use with caution in liver disease Drug interactions increased Great for penicillin allergic patients

Macrolide antibiotic Dosing regimen increases compliance OK in pregnancy and children Less GI effects than erythromycin Less drug interactions than other macrolides Drug of choice for chlamydial conjunctivitis

Z-pack 500mg day one; 250mg days 2-5 Great for compliance For milder infections

Treatment of chlamydia with 1 g dose Prescribe four 250mg tablets Take all at once

4/10/2012

8





ADDRESS_____________________________________________________DATE 3-3-12

Rx Zpak






ADDRESS_____________________________________________________DATE 3-3-12

Rx Zithromax 250mg #4Take 4 pills all at once


Sulfamethoxazole/Trimethoprim Septra DS, Bactrim DS Can use in PCN allergic patients CANNOT use if Sulfa allergic Great gram positive and gram negative

coverage Covers MRSA

Consider if cellulitis plus abscess and severe pain

Sulfa allergy not sulfur allergy Rash is common sign; usually seen in the

antibiotic class of sulfonamides (like Septra®

or sulfacetamide ointment) Less likely to see in non-antibiotic meds Diamox®, Neptazane®, Azopt®, Trusopt®,

Cosopt®

Even less likely to see with topical medications

Sulfites and sulfates are chemically different-no cross reactivity with sulfa allergies

4/10/2012

9

Inhibits bacterial protein synthesis Tetracycline, Doxycyline, Minocycline Cannot use in children younger than 8 Cannot use in pregnancy/nursing Causes photosensitivity and photophobia Long-term therapy associated with

pseudotumor cerebri (rare) Minocycline more than other forms

Good broad spectrum activity qd to bid dosing Can take with food Can take with dairy products Cannot take with antacids Cannot take before lying down

Must wait 2 hours Esophageal ulceration





ADDRESS_____________________________________________________DATE 3-3-12

Rx Doxycycline 100mg1 po bid #20Take with food


Antibiotic use 100mg bid x 10 days

Posterior blepharitis and Dry eye 50mg bid x 4-6 weeks then 50mg qd x 3-6 months or indefinitely Dermatologist to prescribe

4/10/2012

10

Ciprofloxacin (CIPRO®) is prototype Blocks bacterial DNA synthesis Heavily prescribed for urinary tract

infections Overprescribed in the 1990s Little staph coverage now Mainly used for gram negative urinary tract

infections

Cannot use in patients less than 18 years old May decrease cartilage and bone formation

Cannot use in pregnancy/nursing Cannot use in renal disease Multiple drug and vitamin interactions Musculoskeletal side effects

Arthralgia, tendonitis, tendon rupture

A fluoroquinolone Can be used for patients allergic to PCN

and/or cephalosporin OK for hordeolum/preseptal cellulitis Has some coverage against MRSA 500mg qd x 7-10 days No in children/pregnancy/breast feeding

None are controlled substances Little to no abuse potential Many available in OTC strength Patients vary in response to various products NSAID ACTIONS

Inhibit cyclo-oxygenase pathway Results in decreased prostaglandin formation Reduces pain Reduces inflammation Reduces edema

4/10/2012

11

OTC Ibuprofen 200mg

Motrin®, Advil®, Nuprin®

Naproxen 200mg Alleve®

Rx Ibuprofen 400mg, 600mg, 800mg Naproxen (Naprosyn®) Ketorolac (Toradol®) 10mg Celebrex® 100mg, 200mg Others

Schedule III and IV analgesics Non-scheduled pain meds Corneal abrasions, post-op PRK, post-op

pterygium surgery, etc. Do not use in infectious processes, will mask

pain of worsening infection Short term therapy only recommended Need DEA # to prescribe scheduled meds

4/10/2012

12

Schedule III Central acting narcotic analgesic 325mg acetaminophen + 30mg codeine Tylenol with codeine® elixir is APAP

120mg/5cc with 12mg codeine/5cc Avoid in liver/renal disease/alcoholism No extra Tylenol® in addition No alcohol GI distress and sedation are main side effects





ADDRESS 6565 Golden River Drive, Houston, TX 77082 DATE 3-3-11

Rx Tylenol #3 #20 (twenty)1-2 po q4-6h prn pain

REFILLS-- zero Jill Autry, O.D.MA0123456

4/10/2012

13

Most codeine “allergies” are GI side effects or codeine initiated histamine release “Stomach upset” Flushing Itching

True IgE mediated allergic reaction low Can use hydrocodone because it is a semi-

synthetic form of codeine

Significantly more pain relief and duration of action compared to codeine

More addictive Vicodin® (APAP w/hydrocodone)

500mg APAP + 5mg hydrocodone Schedule III

Vicodin® ES (APAP w/hydrocodone) 750mg APAP + 7.5mg hydrocodone Schedule III

Vicoprofen®

200mg ibuprofen + 7.5mg hydrocodone When Tylenol® is contraindicated/liver disease Schedule III





ADDRESS 6565 Golden River Drive, Houston, TX 77082 DATE 3-3-12

Rx Vicodin 5/500 #20 (twenty)1-2 po q4-6h prn pain

REFILLS-- zero Jill Autry, O.D.MA0123456

Nonbacteriostatic sulfonamide Decreases carbonic anhydrase

Decreases hydrogen and bicarb ion formation Results in decreased aqueous production in

the ciliary body Results in alkaline diuresis in the kidney but

tolerance develops quickly Contraindicated in renal, hepatic, or

respiratory disease

4/10/2012

14

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

4/10/2012

15

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

4/10/2012

16

1. PULL OFF GREY CAP

2. HOLD FLUSH TO MID-THIGH.

3. PRESS HARD; WILL HEAR CLICK.

4. LEAVE FOR 10-15 SECONDS.

Found in tears Can use for epithelial disease if patient can’t

use Viroptic®/Zirgan® secondary to toxicity/severe dry eye/availability

Does not help in the treatment of stromal disease

Treat stromal disease with topical steroid Cover steroid with Viroptic®/Zirgan® or

oral antiviral

For Herpes Zoster (shingles) treatment For Bell’s Palsy treatment Must start within 72 hrs for best effect;

preferably within 24 hrs Acyclovir 800mg 5X day Famvir 500mg tid Valtrex 1 gram tid

Herpes simplex keratitis In place of topical treatment

Acyclovir 400mg 5x day x 10 days Famvir® 250mg tid x 7 days Valtrex® 500mg tid x 7 days

For prevention of recurrences Acyclovir 400mg qd-bid Famvir® 250mg qd Valtrex® 500 qd

4/10/2012

17

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

4/10/2012

18

Take with food or milk Generally start 60-80 mg/day

For posterior uveitis, Giant cell, after IV steroids for optic neuritis, pseudotumor, scleritis

Must taper dosage over 1-2 weeks depending on response

40-60 mg x 2-3 days does not need taper Otherwise taper by 20% every few days unless on

steroids for months (then taper more slowly) Consider Medrol Dosepak

For allergic reactions, zoster, anterior uveitis Less serious inflammations




NAME Joe Johnson AGE ______________

ADDRESS_____________________________________________________DATE 3-3-12

Rx Prednisone 20mg #303 tabs (60mg) qd with food/milk

REFILLS-- 0 _____________




NAME Joe Johnson AGE ______________

ADDRESS_____________________________________________________DATE 3-3-11

Rx Medrol Dose PackTUD

REFILLS-- 0 _____________

4/10/2012

19

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)

4/10/2012

20

Patients should discontinue the medication as quickly as possible

Must be tapered-cannot stop abruptly Hyperosmotic therapy Cycloplegic Topical antiglaucoma agents Reported more with hyperopes

Increased risk of retinopathy: > 5 years use Cumulative dose > 1000 g Daily dose > 400 mg/day Elderly Kidney or liver disease Concurrent retinal/macular disease

4/10/2012

21

http://www.alberta-retina.com/Alberta%20Retina%20Consultants/Patient%20Info/Eye%20Diseases/Images/Plaq%20toxicity.jpg

Revised recommendations on screening for chloroquine and hydroxychloroquineretinopathy 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.

Baseline examination Within 1st year of therapy Counsel patient about risk

Annual screening MINIMAL guidelines Begin immediately if high risk Begin after 5 years of use All patients

If toxicity Consider discontinuing medication Slow clearing Visual function may continue to deteriorate

Optic neuropathy Optic neuropathy secondary to decreased

axoplasmic flow Resulting optic nerve edema Seen within weeks of initiation of drug Visual acuity less affected than AION Discontinue use Disc edema will resolve over months

4/10/2012

22

See the TOA Website for more details about any of

our programs and issueshttp:/texas.aoa.org

april 5, 2012 - oral meds and the eye

Health & Medicine