JAM

John A. McGreal Jr., O.D.

St. Louis, MO

John A. McGreal Jr., O.D.

St. Louis, MO

My Top 10 Favorite Oral My Top 10 Favorite Oral DrugsDrugs

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FexofenadineFexofenadine Antihistamines

– Oral drug of choice / non-sedating – 60mg, 180mg, available with decongestant– Dosage: bid, qd– Re-engineered Seldane / free of adverse cardiac effects of

Seldane and Hismanal– Available as Available as

Allegra 60mg bidAllegra 60mg bid Allegra 180 qdAllegra 180 qd Allegra-D 12hr (60/120) for nasal congestionAllegra-D 12hr (60/120) for nasal congestion Allegra-D 24hr (180/240) for nasal congestionAllegra-D 24hr (180/240) for nasal congestion

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DoxycyclineDoxycycline Antibiotic – old and not very good for staph or strep

– Long acting– 20, 50, 75, 100mg capsules

Excellent for meibomian gland dysfunction, blepharitis, ocular acne rosacea– Useful in minimizing structural damage from collagenase in cases of

chemical burns, severe infectious ulcers, RCE

Dosages: 20, 50,75, 100mg PO bid– Rosacea: 100mg bid X 1 mos, then 100mg qd X 2 mos

Available as Doxycycline, Vibramycin, Alodox, NutriDox

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New Ideas in Eyelid CareNew Ideas in Eyelid Care Baby shampoo based scrubs dry out the eyelid skin & Baby shampoo based scrubs dry out the eyelid skin &

remove antibacterial skin oilsremove antibacterial skin oils Scrubbing eyelid skin increases bacterial penetration Scrubbing eyelid skin increases bacterial penetration

and colonizationand colonization No shampoo based products have antibacterial effectNo shampoo based products have antibacterial effect

– Anterior or posterior blepharaits patienyts have bacterial Anterior or posterior blepharaits patienyts have bacterial overgrowth on thei eyelidsovergrowth on thei eyelids Anterior – greasy skin flakes on lashes and inflammation on the Anterior – greasy skin flakes on lashes and inflammation on the

anterior lid marginanterior lid margin Posterior – overgrowth results in sandy gritty irritation in morningPosterior – overgrowth results in sandy gritty irritation in morning

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New Ideas in Eyelid CareNew Ideas in Eyelid Care Production of bacterial lipases and esterases hydrolyze Production of bacterial lipases and esterases hydrolyze

the wax and sterol esters in the meibum, creating free the wax and sterol esters in the meibum, creating free fatty acids that irritate the eye and may promote fatty acids that irritate the eye and may promote inflammation and resultant changes in tear film stabilityinflammation and resultant changes in tear film stability

Dry eye patients also have bacterial overgrowth on their Dry eye patients also have bacterial overgrowth on their eyelidseyelids– This bacteria inhibits conjunctival goblet cells proliferation This bacteria inhibits conjunctival goblet cells proliferation

in tissue culture, relative to normal controlsin tissue culture, relative to normal controls Mucus from these cell lubricates the ocular surfaceMucus from these cell lubricates the ocular surface Dry eye patients already have decreased goblet cell density Dry eye patients already have decreased goblet cell density

secondary to increased tear film osmolaritysecondary to increased tear film osmolarity Punctal plugs are covered in a biofilm colonized by a diversity of Punctal plugs are covered in a biofilm colonized by a diversity of

organismsorganisms

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Blepharitis Therapy – Topical/OralBlepharitis Therapy – Topical/Oral NutriDox Convenience KitNutriDox Convenience Kit

– Doxycycline 75mg tabletsDoxycycline 75mg tablets Works synergistically with SteriLid to reduce bacterial colonizationWorks synergistically with SteriLid to reduce bacterial colonization Works synergistically with Theratears Nutrition to suppress Works synergistically with Theratears Nutrition to suppress

inflammation inflammation 30 tablets of antibiotic30 tablets of antibiotic

– TheraTears Nutrition omega-3 softgels (#90)TheraTears Nutrition omega-3 softgels (#90) Thins meibomian secretions and reduces inflammationThins meibomian secretions and reduces inflammation

– iHeat Warm Compress SystemiHeat Warm Compress System iHeat Mask iHeat Mask iHeat Warming Units (#10)iHeat Warming Units (#10)

– Activated by pressing on them, maintains heat for 5 minsActivated by pressing on them, maintains heat for 5 mins

– Indications: Moderate-severe posterior blepharitisIndications: Moderate-severe posterior blepharitis

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Blepharitis Therapy – Topical/OralBlepharitis Therapy – Topical/Oral ALODOX Convenience KitALODOX Convenience Kit

– Doxycycline 20mg (low dose) tabletsDoxycycline 20mg (low dose) tablets Below antimicrobial level, safer for prolonged useBelow antimicrobial level, safer for prolonged use Sustains collagenolytic activity, reducing inflammationSustains collagenolytic activity, reducing inflammation

– Ocusoft Lid Scrub Plus (Cynacon/Ocusoft)Ocusoft Lid Scrub Plus (Cynacon/Ocusoft) 1 box of pre-moistened pads1 box of pre-moistened pads 60 tablets of antibiotic60 tablets of antibiotic 1 bottle of 50ml Ocusoft Lid Scrub Original Formula1 bottle of 50ml Ocusoft Lid Scrub Original Formula Covered by most insurances as tier 3 co-payCovered by most insurances as tier 3 co-pay

– $25.00 rebate$25.00 rebate– Assistance program through Assistance program through www.rxhope.com

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CephalexinCephalexin Action – cephalosporin

– Gram positives, skin & skin structures Dosage:

– 1-4g/D; – 250mg qid, – 500mg bid, tid, qid, – 750mg bid

Contraindication: PCN allergy Side effects - min Available as Keflex, Keftab, Keflet

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ErythromycinErythromycin Macrolide for skin & skin structures Side effects – nausea, vomiting, diarrhea Dosage: 200, 250 (generic), 333 (Filmtabs or PCE), 400, 500mg

(E-mycin) Available as 50 varieties with GI upset; 3 with enteric coated

formulations to minimize side effects– Erythromycin ethylsuccinate (EES 400mg qid)– Erythromycin particles (PCE Dispertab 333mg tid, 500mg bid)– Erythromycin delayed (ERYC 250mg qid)

Available as Ilotycin ophthalmic ointment

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AzithromycinAzithromycin Macrolide

– Drug of choice in children and adults, particularly in PCN allergy– Long half life– Excellent bioavailability

Side effects similar to erythromycin but less Dosage: Z-PAK 500mg / day 1, then 250mg / days 2-5 Dosage: TRI PAK 500mg qd for three days Dosage: ZMAX single 2.0g dose Pediatric dose: 12mg/kg/D Available as

– Zithromax Z-Pak, Zithromax TRI PAK, ZMAX, AzaSite topical Simple, convenient, effective

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AcyclovirAcyclovir Antiviral for simplex, zoster & chickenpox Dose form – 200, 400, 800mg tablets, 200mg/5ml

– Primary Herpes Simplex: 400mg- 5x/D x10D– Chronic Suppressive: 400mg bid daily for prophylaxis x 1yr– Varicella: elixir 20mg/kg per dose- 4x/D x 5D (initiate within 24h)

Children over 40kg receive adult dose

– Herpes Zoster: 800mg- 5x/D x 10D (initiate within 72h, 48h best) Expensive Side effects: nausea, diarrhea Only caution is with renal impairment Available as Zovirax

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MethylprednisoloneMethylprednisolone Oral corticosteroid Indications: Allergic reactions, dermatologic reactions,

stubborn iritis witch is slow to respond to intensive topical steroids, Bell’s palsey

Side effects – avoid in diabetics, otherwise safe for short term applications

Dosage: 6 day, 21 tablet, self-tapered dose form Available as Medrol 4mg DOSPAK (generic)

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Types of AnalgesicsTypes of Analgesics Narcotic analgesics

– Opiates or opioids– Controlled substances – Actions

Bind to opiod receptors in the brain, brainstem, and spinal cord Mimic the effect of endogenous opioid peptides (endorphins) Affect both the sensation of noxious stimulation and the emotional

component of subjective distress– Clinical stratification of pain

Mild to moderate pain Moderate to severe pain Most severe

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Narcotic AnalgesicsNarcotic Analgesics Side effects

– CNS Sedation, lightheadedness, dizziness, drowsiness, euphoria

– GI Nausea, vomiting, constipation

– Respiratory depression Contraindications

– Hypersensitivity to narcotics– Respiratory disease– Kidney or liver diseases

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Oral Narcotic Analgesic - GuidelinesOral Narcotic Analgesic - Guidelines Prescribing hints

– Never exceed maximum recommended amounts ASA - 8g/D APAP - 4g/D Ibuprofen - 1200mg/D OTC & 2400mg/D Rx Codeine - 360mg/D

– All have abuse potential– Precautions

No EtOH Do not operate machinery

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Oral Narcotic Analgesic - GuidelinesOral Narcotic Analgesic - Guidelines Establish the proper diagnosis Treat the underlying disease (root-cause) Treat pain with the simplest and safest means to

achieve comfort and adjust the treatment according to response or patient threshold

Treat pain at presentation – do not wait! Treat pain continuously over 24h schedule Nonprescription drugs are usually a low-cost effective

first choice

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Oral Narcotic Analgesic - GuidelinesOral Narcotic Analgesic - Guidelines Mild to moderate pain is often successfully treated

with NSAIDs and acetaminophen Moderate to severe pain is best treated with opiod

analgesics Adjunctive treatments are very valuable in pain

management– “RICE” – rest, ice, compression, elevation– Mydriatic / cycloplegia useful with ciliary ocular pain – Bandage contact lenses or pressure patches for epithelial

defects

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CodeineCodeine

APAP / Codeine 15, 30, 60mg (Tylenol #2, 3, 4) ASA / Codeine 15, 30, 60mg (Empirin #2, 3, 4) Schedule III Side effects

– Lightheadedness, dizziness, sedation, nausea, vomiting, euphoria, constipation

Pediatric dose – 0.5mg/kg/day– 3-6 yrs 5ml tid-qid (1 teaspoon)– 7-12 yrs 10ml tid-qid (2 teaspoons)

Hydrocodone Hydrocodone Actions – narcotic analgesic and anti-tussive Combination with acetaminophen mostly, some

ibuprofen Uses

– Moderate –moderately severe pain– Cautious use in elderly debilitated patients with renal or

hepatic problems Dose q4-6h Available as Vicodin 5mg/500mg

Hydrocodone Hydrocodone Vicodin 5/500mg APAP Vicodin ES 7.5/750mg APAP Vicodin HP 10/660mg APAP Vicoprofen 7.5/200mg Ibuprofen Hycodan 7.5/1.5mg homatropine methylbromide

– Subtherapeutic dose of HA for antitussive affect Lorcet 10/650mg APAP Lorcet HD 5/500mg APAP Lorcet Plus 7.5/650mg APAP Zodone 5/400, 7.5/400, 10/400mg APAP

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AcetazolamideAcetazolamide Oral CAI with attendant side effects 250mg, 500mg sequels (time released) Dosage – qid for 250mg, 500 bid for sequels

– Sequels best for reduced side effects in long term chronic use but never use sequels for acute glaucoma

Side effects – paresthesias of fingers and lips, acid-base shifts, urinary calculi, impotence, thrombocytopenia, hypokalemia– OJ or banana or supplemental potassium to limit side effects, periodic

CBC

Contraindicated in sulfa allergy Excellent as quick IOP lowering agent in acute glaucoma Available as Diamox

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EyePromise RestorEyePromise Restor Oral supplement for macular degeneration and at risk groups

– Improves MPOD over 6-12 months, reduces glare, improves contrast sensitivity

– Beneficial for dry eye, cataracts and wellness along with multivitamins

Ingredients– No beta-carotene or vitamin A– Vitamin C– Vitamin E– Zinc– Lutein– Zeaxanthin– Omega-3s– Alpha-linoleic acid

Is MPOD Related to AMD?Is MPOD Related to AMD?

Three donor eye studies published, all show 30-50% less pigment in AMD eyes vs controls

Moran Eye Center (Bernstein) Raman method Manchester UK group HFP method found AMD patient

eyes had 50% lower MPOD Germans found 50% lower MPOD in dry AMD patient

eyes Dutch group did cross sectional prospective study using

reflectance and found no difference on MPOD in early AMD

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Macular Pigment StudiesMacular Pigment Studies

Optom 2008; 79:266-272 Lueng – Optometrist play key role in assessment & monitoring risk of

AMD LAST Study (Lutein Antioxidant Supplement Trial)

– 12 month study– 90 male VA patients

Lutein 10mg vs Lutein 10mg & MV vs Placebo

– Lutein only or combination increases MPOD by >50%, Glare recovery, contrast sensitivity and visual acuity

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Macular Pigment StudiesMacular Pigment Studies

OptomVisScience 2008; Stringham & Hammond– Six months of L/Zx increased MPOD– Decreased glare disability 58%– Decreased photostress recovery time 14%

Ophthal 2008 Feb 115(2):334-341 Blue Mountain Eye– Higher intake of L/Zx reduced risk of AMD– Confirmed protective benefit of zinc– Higher beta carotene increased risk AMD

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Macular Pigment Studies in CataractsMacular Pigment Studies in Cataracts

ArchOphthal 2008; Mueller et al– CAREDS/WHI– N=1802 women with highest levels of L/Zx had 32% lower

incidence of NSC Ophthal 2008 115(8) Sperduto et al

– NEI Trial of Centrum Silver– N=1020 18% less lens events

AmJClinNut 2008; Tan et al Blue Mountain Group– N=2464 Vit C and dietary antioxidants decreased NSC 50%

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Macular Pigment Studies in DiabetesMacular Pigment Studies in Diabetes

IOVS 2008; Gierhardt et al– Proved Zx mechanism of protection in early DR

Anti-inflammatory & VEGF regulation

CAREDS 2007 Diabetic women have 30% lower MPOD

Graetes 2008 Spanish Group– Fed diabetic rats lutein and found it to be as effective as

insulin at preventing cataract

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NutritionalsNutritionals EyePromise (ZeaVision)

– Zeaxanthin 8mg in the same 2:1 ratio as found in healthy macula

– Lutein 4mg– Beta carotene – none– Vitamin C – 120mg– Vitamin E – 60 IU– Zinc – 15mg– Copper – none– Fish oil (omega-3) – 250mg– Alpha Lipoic acid – 10mg

Cardiovascular PreventionCardiovascular Prevention

Bonus Round

Oral NSAID - AspirinOral NSAID - AspirinAspirin (ASA) – salicylic acid derivative

– Anti-platelet activity at low dosages (D/C prior to surgery)– Primary action is to reduce hypothalamic prostaglandin levels at

average doses (325-1000mg q4-6h)– Significant anti-inflammatory effects at higher doses (600-5200mg

daily)– Preventative effects at low doses (81mg)– Side effects

Hypersensitivity reactions GI upset, bleeding Salicylism at high doses (dizziness, tinnitus, headache) Associated with Reyes' Syndrome in children with fever and viral illness Blurred vision and color changes Caution in asthmatics

– Lethal dose is 10-30g (adults) and 4g (children)

Oral NSAIDsOral NSAIDsAspirin (ASA) – salicylic acid derivative

– Aspirin (generic) 325mg, 81mg (low dose) as daily prohylactic for at risk groups

– Bayer 325mg– Empirin 325mg– Ecotrin 325mg

Enteric coated

– Ascriptin 325mg Coated, buffered

– Bufferin 325mg Coated, buffered

Oral NSAIDsOral NSAIDsAspirin (ASA) – salicylic acid derivative

– Aspirin (generic) 325mg, 81mg (low dose) as daily prophylactic for at risk groups

– Bayer Children Low Dose 81mg (chewable cherry & orange)– St. Joseph 81mg chewable & enteric coated – Aggrenox – ASA 25mg & dipyridamole 200mg extended

release form Indicated to reduce risk of stroke in patients with TIAs or completed

stroke due to thrombosis

– Butalbital/ASA/Caffeine– Butalbital/ASA/Caffeine/Codeine

Oral NSAIDsOral NSAIDs

Aspirin (ASA) – non-narcotic combinations– Anacin caplets Aspirin 400 / Caffeine 32– Anacin (max) Aspirin 500 / Caffeine 32– BC Powder Aspirin 650 / Caffeine 32 / Salicylamide

195

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Thrombolytics for MI Thrombolytics for MI Acute Coronary Syndromes

– Reteplace (Retavase)– Eptifibatide (Integrilin)– Tirofiban (Aggrastat)– ASA (Bayer) 325mg chewed STAT– Drug-eluting or bare metal stents

Prevention– ASA 81mg (only 1/3rd of 62 million at risk in US use ASA)

Reduces 1st MI risk by 32%, 2nd MI risk by 20%

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Thank youThank you

An educational affiliate of Missouri Eye AssociatesAn educational affiliate of Missouri Eye Associates

McGreal Educational Institute

McGreal Educational Institute