April 5, 2012 - Oral Meds and the Eye

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

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

4/10/2012

 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

4/10/2012


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
Houston, TX 77089
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)

 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

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


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


6

4/10/2012


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
 Drug interactions increased
ADDRESS_____________________________________________________DATE 3-3-12  Great for penicillin allergic patients
Rx Omnicef 300mg #14
1 po bid UAT


 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

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


 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

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


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


9

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

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

4/10/2012


Phone (713)797-1010 Phone (281)998-3333 (281)277-1010

 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

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


Phone (713)797-1010 Phone (281)998-3333 (281)277-1010

450 Medical Ctr Blvd, #305
Webster, TX 77598
Houston, TX 77089
Katy, TX 77450
 Nonbacteriostatic sulfonamide
(281) 332-1397 (281) 484-2030 (281) 578-4815
 Decreases carbonic anhydrase
 Decreases hydrogen and bicarb ion formation
 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

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

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

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

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

4/10/2012


Phone (713)797-1010 Phone (281)998-3333 (281)277-1010
 Take with food or milk
Generally start 60-80 mg/day
 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 _____________


Phone (713)797-1010 Phone (281)998-3333 (281)277-1010

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

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

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

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

4/10/2012

See the TOA Website for more
details about any of
our programs and issues
http:/texas.aoa.org

22

April 5, 2012 - Oral Meds and the Eye

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April 5, 2012 - Oral Meds and the Eye