Oral Pharmaceutical Agents for the Treatment of Anterior Segment Pathologies Greg Caldwell, OD, FAAO 225 Terrace Drive Lilly, PA 15938 814-931-2030 mobile Grubc@aol.com Abstract This course will review the usage of oral antibiotics and oral anti-virals for ocular infections and oral analgesics/narcotics for ocular pain management. Practical information regarding the identification of adverse/allergic reaction, dialysis, pregnancy and maximum daily doses will be discussed, which are prerequisites before prescribing oral pharmaceutical agents. Course Objectives To review adverse/allergic reactions to oral medications To review the FDA Pregnancy Categories for medications To discuss renal impairment and its impact on prescribing oral medications To identify and review the most appropriate oral antibiotics or anti-virals for usage in ocular infections, so one can implement a timely and effective treatment To review oral analgesics/narcotics for ocular pain management to ensure proper and effective treatment To furnish the clinician with pearls, therapeutic options and guidance around pitfalls. Outline I. Medical History Chief complaint History of the present illness Review of systems Dialysis Past, Family and Social history Current medications Allergies/Adverse reactions Pregnancy II. Adverse Reaction/Allergic Reaction Hypersensitivity Fever Rash Photosensitivity ANAPHYLAXIS Hematologic Neutropenia 2 Eosinophilia Increase in PT/PTT Gastrointestinal Nausea Vomiting Diarrhea Liver failure Central nervous system Ototoxicity Cardiac Dysrrhymia III. FDA Pregnancy Categories Category A Studies in pregnant women No risk Category B Animal studies no risk but human not adequate…or Animal toxicity but human studies no risk Safe Category C Animal studies show toxicity human studies inadequate but benefit of use may exceed risk Avoid Category D Evidence of human risk but benefits may out weigh risks Avoid Category X Fetal abnormalities Risks > benefits Avoid IV. Renal Impairment Identify patients on hemodialysis Adjustment made by patient’s creatinine clearance (CrCl) ml/min Work with patient’s primary care physician or internist V. Case 1- Dacryocystitis, Preseptal Cellulitis and Bacterial Conjunctivitis 58 year old male with red and painful OS Visual acuity 20/20 OD, 20/60 OS Picture of above conditions Patient is allergic to Penicillin and Keflex Treatment Polytrim gtts QID OS Zithromax 1 Z-pack, use as directed PO 3 Dilation and irrigation Contraindication Indication Confirmed nasolacrimal duct blockage, dacryocystorhinostomy DCR Group discussion on treatment VI. Augmentin Amoxicillin and potassium clavulanate Kills everything, good for everyone 12 weeks old and older Safe in pregnancy, category B Watch for Penicillin allergies Adults: 500mg BID (875mg BID) Children < 100 pounds, oral suspension 25-45 mg/kg divided into two doses Covers Staph, Strep, and Haemophilus influenzae VII. Zithromax (azithromycin) Macrolide antibiotic Like erythromycin Drug of choice in Penicillin sensitive patients All age groups Safe in pregnancy, category B No renal adjustment Adults: 250mg BID, day 1 and 250mg QD, day 2-5 Dispense: 1 Z-pack as directed Children <16: 10mg/kg, day 1 and 5mg/kg, day 2-5 Covers Staph, Strep, and Haemophilus influenza Better tolerated than erythromycin, little GI upset Chlamydia, 1 gram QD VIII. Keflex (cephalexin) Cross reaction with Penicillin sensitive patients First generation, moderately affective against Penicillin-ase Good for gram +, not good for Haemophilus which is gram – Category B Adult: 500mg BID for one week Drug of choice for blow out fractures IX. Ceftin (cefuroxime) Cross reaction with Penicillin sensitive patients Second generation Better for Haemophilus (-) Children: 3 months to 12 years old, oral suspension 20-30mg/kg/day divided into two doses Adults: 250mg BID for 10 days 4 Category B X. Cipro (ciprofloxacin), Levoquin (levofloxacin) End of the line antibiotic Really effective Category C Avoid during pregnancy Only use if 18 years old or older 500mg BID for one week, Cipro 500mg QD for one week, Levoquin XI. Sulfa Drugs Bactrim (sulfamethoxazole/trimethoprim) Limited use…last line of defense High incidence of Steven-Johnsons Avoid in pregnancy Category C Avoid in sickle cell disease Cross reaction with: Oral hypoglycemics Carbonic anhydrase inhibitors Celebrex Thiazide diuretics All are sulfa based Bactrim BID for ten days Bactrim DS BID for ten days XII. Summary Adults Augmentin Zithromax Keflex Cipro Bactrim Children Augmentin Zithromax Ceftin Avoid Cipro Bactrim XIII. Case 2- Rosacea Blepharitis 48 year old male both eyes are red, gritty, sandy and dry Visual acuity 20/20 OU Show multiple pictures of rosacea, lid margins and conjunctiva Treatment 5 Warm compresses Lid hygiene Artificial tears Doxycycline 100mg QD for at least one month Dermatological consult Group discussion on treatment XIV. Vibramycin (doxycycline) Drug of choice for marginal inflammatory blepharitis Antibiotic, anti-inflammatory and anti-collagenase Inhibits the lipase enzyme Avoid in children Category D Avoid in pregnancy No renal adjustment Can enhance coumadin 50-100mg QD for 2-12 weeks XV. Final Thoughts Penicillin, Ampicillin and Amoxicillin are of no benefit for treating ocular infections Popular Penicillin derivative, Dicloxacillin 250mg QID for a week XVI. Case 3- Varicella Zoster Virus, Herpes Zoster Ophthalmicus 52 year old male with red and painful OD Visual acuity 20/30 OD, 20/20 OS Show multiple pictures of lids and conjunctiva Group discussion on treatment XVII. Oral Anti-Virals Third generation, go into every cell but only activate in viral infected cells First generation were mutogenic Can be used prophalactically prior to PKP, LASIK or PTK XVIII. Zovirax (acyclovir) Good for simplex Poor absorption Dosage: 800mg 5 times per day Maintenance dose: 200-400mg BID Category B XIX. Famvir (famcyclovir) Proven to reduce post-herpetic trigeminal neuralgia Drug of choice for zoster patients 50 years old and older Dosage: Zoster 500mg TID 6 XX. Recurrent simplex 125-250mg BID Category B Valtrex (valacyclovir) Pro-drug of acyclovir GI upset HSV-1, HSV-2 and VZV Dosage: 1 g TID for one week Category B XXI. Case 4- Recurrent Herpes Simplex Keratitis 47 year old female with a red and painful OD Visual acuity 20/30 OD, 20/20 OS First episode Group discussion on treatment Second episode Group discussion on treatment Third episode Group discussion on treatment XXII. Herpetic Eye Disease Study HEDS I Benefit from steroids in stromal keratitis No benefit from oral acyclovir in stromal keratitis Benefit from steroids if iritis present HEDS II No benefit from acyclovir to stop progression to stromal or iridocyclitis Maintenance dose 400mg BID, decreases recurrence by 41% within first year XXIII. Questions XXIV. Thank-you