Course #
122
Pharmaceutical Clinical Pearls
PHARMACEUTICAL
CLINICAL PEARLS
Disclosures – Jill Autry, OD, RPh
• Speaker’s Bureau/Consultant/Advisory Board
–
–
–
–
–
Allergan
Alcon
Ista
Bausch and Lomb
Varilux
• Owner/Partner
Jill Autry, OD, RPh
Eye Center of Texas, Houston
drjillautry@tropicalce.com
Supported by and educational grant from Bausch and Lomb
MAIL ORDER
• Have mail order program?
– Chronic medications like glaucoma drops,
doxycycline, Restasis®
– Must write “Dispense 90 day supply” on Rx
– Cheaper and better compliance w/3 mo supply
– Write two scripts initially
– Tropical CE
– Eye Center of Texas Ophthalmology Center, Houston
• Editorial Board/Columnist
– Primary Care Optometry News
– Optometry Times
– Review of Optometry
INDIGENT PROGRAMS
• Allergan (Lumigan, Alphagan, Combigan,
Restasis)
– 1-800-553-6783
– www.rxhope.com/allergan
• Alcon (Azopt, Travatan, Betoptic S)
– 1-800-222-8103
• Immediate script for drugstore
• Separate script for mail order
– Now done locally at most Walgreens and CVS’
FOR MEDICAID
• Many states get a certain # scripts a month free
• Everything else they pay for unless certain
conditions/age
– End stage renal disease/blindness
– Children/pregnancy
– Institutionalized/nursing home
• Some states brand # capped/unlimited generics
• medicaidbenefits.kff.org
• Approved meds often change yearly
• Prior authorization in place for most states
WHAT IS
PRIOR AUTHORIZATION?
• Must meet certain requirements before authorizing
payment for Rx
• Pharmacist receives a rejection statement from
insurance company
• Tells patient or calls physician regarding prior
authorization
• Physician must call insurance company to provide
information
• Insurance company may or may not authorize
payment
1
PRESCRIBING FOR WOMEN
• Pregnant/nursing or thinking about it?
PRESCRIBING FOR WOMEN
• On birth control pills?
– Consult OB-GYN if necessary
– OK in pregnancy
• Augmentin, erythromycin, Zpack,
amoxicillin, tobramycin
• Tylenol #3, Vicodin (better choice for
breastfeeding)
• Prednisone (oral and topical) when
necessary
• Acyclovir and other oral antivirals
– Only antibiotic proven to interfere with birth
control pills is Rifampin
– True interaction with other antibiotics not
clinically established
– However, counsel and document for
concomitant antibiotic therapy
• OK to dilate in pregnancy
• No doxycycline during pregnancy/breast
feeding
PREGNANCY PEARLS
• No prostaglandins
• IOP goes down with every trimester
– Consider SLT
– brimonidine is only Category B glaucoma med
• Fluoroquinolones
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–
–
–
No oral fluoroquinolones
Weight risk/benefit for topical treatment
May have to compound for Class B status
Topical tobramycin is Class B
MUCOMYST
• Mucomyst can be compounded for
filamentary keratitis
• 2.5-5% compounded for ocular use
• Consult a compounding pharmacist
• Use tid-qid
• Must control underlying dry eye
MURO 128 5%
•
•
•
•
•
Solution and ointment; both sting
Generic available
Works for corneal epithelial edema
Use ointment nightly for severe Fuch’s
For recurrent erosions, use ointment nightly
for 6 weeks after bandage CL
• Use solution for easy removal of BCL
TOPICAL STEROIDS
•
•
•
•
•
No generic!!!
Pred Forte 1% is my gold standard
Durezol for heavy inflammatory conditions
Lotemax for known steroid responders
Almost always start q2h unless dry eye or
milder inflammation
– Iritis, episcleritis, Thygeson’s, sterile ulcers,
staph exotoxin keratitis
2
TOPICAL STEROIDS
• Start q30 minutes for SOS or other type of
severe inflammation
• If IOP goes up, start Alphagan/Cosopt or
Combigan
• Avoid prostaglandins when possible with
inflammatory conditions
• Taper in 4 day intervals in most acute cases
STEROIDS AND IOP
• All steroids can cause increased IOP
– Oral, topical, inhaled, injected, nasal
• 5% of the general population will be steroid
responders
• 95% of glaucoma patients will be steroid
responders
• Once taper over take bottle from patient
Edward Wade, M.D.
Chris Allee, O.D.
STEROID FOR SKIN
• Contact dermatitis
• Allergic reaction to skin surrounding ocular
area
• Triamcinolone 0.1% cream or ung
• Avoid eye contact
4415 Crenshaw Rd.
Pasadena, TX 77504
Phone (281)998-3333
15400 SW Frwy
Sugar Land, TX 77478
(281)277-1010
450 Medical Ctr Blvd, #305
Webster, TX 77598
(281) 332-1397
11914 Astoria Boulevard, #325
Houston, TX 77089
(281) 484-2030
21700 Kingsland Blvd.
Katy, TX 77450
(281) 578-4815
NAME
Joe Johnson
AGE ______________
ADDRESS_____________________________________________________DATE
Rx
3-3-11
Triamcinolone 0.1% cream 15g
Apply small amount bid OU
to lower eyelid area x 2 weeks
0
Jill Autry, O.D.
VIRAL CONJUNCTIVITIS
TOPICAL ANTIBIOTICS
WAY overprescribed!!!
Topical antibiotics for surgical prophylaxis
For prophylaxis with corneal abrasion
For treatment of corneal ulcer
For anterior blepharitis
What about bacterial conjunctivitis….????
Mark Mayo, M.D.
Randy Reichle, O.D.
6565 West Loop South
Bellaire, TX 77401
Phone (713)797-1010
REFILLS--
•
•
•
•
•
•
Ting Fang-Suarez, M.D.
Jill Autry, O.D.
•
•
•
•
•
•
Watery, mucous discharge
Matting
Follicles
Starts in one eye moves to other
May have history of recent viral infection
Adenovirus or Hemorrhagic
3
VIRAL CONJUNCTIVITIS
• Adenovirus
• Hemorrhagic (caused by enterococcus and/or
coxsackie virus)
• Naphcon-A, artificial tears, cold compresses
• Do not start Tobradex emperically
• Need steroid (Pred Forte/Lotemax/Durezol) if:
– Patient develops subepithelial infiltrates
– Patient develops pseudomembranes
– Severe inflammation
PRK PEARLS
• Leave bandage on for 7-10 days
• Toradol or other NSAID post PRK
– Greatly decreases pain following procedure
•
•
•
•
May also need codeine/hydrocodone product
Vitamin C 500mg bid x 3 months post-PRK
Acuvail bid prn due to preservative free
“Comfort drops”
– 10 drops of proparacaine to AT bottle
– Use once an hour prn pain
Autologous Serum Drops
•
•
•
•
•
Utilizes patient’s own blood serum
Replaces individualized growth factors
Replaces individualized antibodies
Requires blood donation 2-3 times yearly
Consider 5-10% serum albumin drops qid
instead
FORTIFIED ANTIBIOTICS
• Find a compounding pharmacist BEFORE
you need them
– www.iacprx.org
• Recommend alternating q 30 minutes to
start
– Vancomycin 25 mg/ml (gram + coverage)
– Ceftazidime 50mg/ml (gram – coverage)
ATROPINE 1%
• Studies show use in non-amblyopic eye works just
as well as patching
– Increased VA 74% vs 79%
– Compliance better 78% vs 49%
• When prescribing a cycloplegic, put a drop of
atropine/cyclopentolate in before patient leaves
office-pharmacy often has to order cycloplegic
• Use with phenylephrine 10% in office to break
synechiae
TOPICAL PEARLS
• Don’t forget punctal occlusion
• Prescribe 1 drop; not 1-2 drops
– The cul-de-sac can’t even hold the first drop
• Beta blockers once daily shows equal efficacy to
twice daily
• Prescribe beta blockers in am to avoid hypotension
• Throw everything in for acute angle closure
– Including prostaglandin and pilocarpine
4
PRESCRIBING FOR CHILDREN
• Children 12 years old and older can be dosed as
adults unless otherwise noted
• Look up dosage for child
– Given in mg/kg/day
• Determine how many kg child weighs
– 1 kg=2.2 lbs
• Multiply mg and kg to get total DAILY dose
• Divide by number of doses per day
• Choose closest available dosage strength
PEDIATRIC DOSING EXAMPLE
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•
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•
40 lb, 5 year old with preseptal cellulitis
1 kg=2.2 lbs.
40 lb/2.2 = 18 kg
Weight in kg approx. ½ weight in pounds
Doctor chooses Augmentin for antibiotic
therapy
PEDIATRIC DOSING EXAMPLE
• 20-40 mg/kg/day of amoxicillin in divided
doses every 8-12 hours
• If patient weighs 88 lb. or more, dose as
adult
40 lb. ÷ 2.2 = 18 kg
________________________
18 kg x 40 mg/kg/day =
727 mg/day
________________________
727 mg/day ÷ 3 = 242 mg q8h
________________________
Round to 250 mg q8h
DOSAGE CALCULATION
•
•
•
•
40mg/kg/day divided q8h
18 kg x 40mg=727 mg/day
Divide 727 mg by 3 (i.e. q8h)
=242mg q8h
HOW SUPPLIED
• AUGMENTIN 125 mg/5 mL
– 75 mL bottle, 100 mL bottle, 150 mL bottle
• AUGMENTIN 200 mg/5 mL
– 50 mL bottle, 75 mL bottle, 100 mL bottle
• AUGMENTIN 250 mg/5 mL
– 75 mL bottle, 100 mL bottle, 150 mL bottle
• AUGMENTIN 400 mg/5 mL
– 50 mL bottle, 75 mL bottle, 100 mL bottle
5
Edward Wade, M.D.
Chris Allee, O.D.
READY TO PRESCRIBE
• Prescribe 250mg/5ml; 1 tsp q8h
• #150ml gives 10 day course
Ting Fang-Suarez, M.D.
Jill Autry, O.D.
Mark Mayo, M.D.
Randy Reichle, O.D.
6565 West Loop South
Bellaire, TX 77401
Phone (713)797-1010
4415 Crenshaw Rd.
Pasadena, TX 77504
Phone (281)998-3333
15400 SW Frwy
Sugar Land, TX 77478
(281)277-1010
450 Medical Ctr Blvd, #305
Webster, TX 77598
(281) 332-1397
11914 Astoria Boulevard, #325
Houston, TX 77089
(281) 484-2030
21700 Kingsland Blvd.
Katy, TX 77450
(281) 578-4815
NAME
Morgan Smith
AGE ___5__
ADDRESS_____________________________________________________DATE
Rx
REFILLS--
3-3-11
Augmentin 250/5
1 tsp q8h x 10 days #150
0
Jill Autry, O.D.
ORAL ANTIBIOTIC USES
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•
Preseptal cellulitis
Dacryocystitis
Dacryoadenitis
Canaliculitis
Chlamydia
Dry eye/posterior blepharitis/ocular rosacea
Posterior toxoplasmosis
Endophthalmitis prevention
6
CHLAMYDIA
• Suspect with conjunctivitis lasting 1 month or
more
• Follicles unilateral or bilateral
• Clear, ropy discharge
• Check for PA node
• Prescribe Zithromax 1 gram in a single dose
• Erythromycin ointment and PF to eyes
Edward Wade, M.D.
Chris Allee, O.D.
Ting Fang-Suarez, M.D.
Jill Autry, O.D.
Mark Mayo, M.D.
Randy Reichle, O.D.
6565 West Loop South
Bellaire, TX 77401
Phone (713)797-1010
4415 Crenshaw Rd.
Pasadena, TX 77504
Phone (281)998-3333
15400 SW Frwy
Sugar Land, TX 77478
(281)277-1010
450 Medical Ctr Blvd, #305
Webster, TX 77598
(281) 332-1397
11914 Astoria Boulevard, #325
Houston, TX 77089
(281) 484-2030
21700 Kingsland Blvd.
Katy, TX 77450
(281) 578-4815
NAME
Jack Cooper
AGE ________
ADDRESS_____________________________________________________DATE
Rx
REFILLS--
3-3-11
Zithromax 250mg #4
Take 4 pills all at once
0
Jill Autry, O.D.
7
SKIN AND SOFT TISSUE
• Amoxicillin 875 1 po bid
• Septra if high risk/history of MRSA
– Septra DS 1 po bid
• PCN allergic
– Septra DS 1 po bid
– Levaquin 500mg q po bid
– Zpack TUD
• Sulfa and PCN allergic
– Levaquin 500mg 1po qd
– Zpack
DOXYCYCLINE
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•
•
•
•
No with children < 8 years old/pregnant/nursing.
OK with food/dairy.
Decreased effect with antacids.
Causes photosensitivity
Also a great antibiotic in higher dose
SULFA ALLERGY
• 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
Edward Wade, M.D.
Chris Allee, O.D.
Mark Mayo, M.D.
Randy Reichle, O.D.
6565 West Loop South
Bellaire, TX 77401
Phone (713)797-1010
4415 Crenshaw Rd.
Pasadena, TX 77504
Phone (281)998-3333
15400 SW Frwy
Sugar Land, TX 77478
(281)277-1010
450 Medical Ctr Blvd, #305
Webster, TX 77598
(281) 332-1397
11914 Astoria Boulevard, #325
Houston, TX 77089
(281) 484-2030
21700 Kingsland Blvd.
Katy, TX 77450
(281) 578-4815
NAME
Jack Cooper
AGE ________
ADDRESS_____________________________________________________DATE
Rx
3-3-11
Doxycycline 50mg
1 po bid #60
Take with food/milk
– 100mg bid x 10 days
REFILLS--
Jill Autry, O.D.
0
Edward Wade, M.D.
Chris Allee, O.D.
DuraSite® Vehicle
Ting Fang-Suarez, M.D.
Jill Autry, O.D.
Ting Fang-Suarez, M.D.
Jill Autry, O.D.
Mark Mayo, M.D.
Randy Reichle, O.D.
6565 West Loop South
Bellaire, TX 77401
Phone (713)797-1010
4415 Crenshaw Rd.
Pasadena, TX 77504
Phone (281)998-3333
15400 SW Frwy
Sugar Land, TX 77478
(281)277-1010
450 Medical Ctr Blvd, #305
Webster, TX 77598
(281) 332-1397
11914 Astoria Boulevard, #325
Houston, TX 77089
(281) 484-2030
21700 Kingsland Blvd.
Katy, TX 77450
(281) 578-4815
NAME
John Jones
AGE ______________
ADDRESS_____________________________________________________DATE
Rx
5-6-11
Azasite 1 gtt qhs OU
2.5 ml x 2 (5ml) for 30 day supply
Apply to lids/lashes qhs x 1 month
REFILLS-- 2
Jill Autry, O.D.
8
TOPICAL PAIN
CYCLOPLEGIA
• “Comfort drops”
– 10 drops of proparacaine to sample Optive tears bottle
– Use once an hour prn pain
– For non-infectious abrasion, post-PRK, postenhancement
• Topical NSAIDS
– Acular much better at pain control than Nevanac
• Don’t forget cycloplegia when appropriate
Edward Wade, M.D.
Chris Allee, O.D.
Ting Fang-Suarez, M.D.
Jill Autry, O.D.
15400 SW Frwy
Sugar Land, TX 77478
(281)277-1010
450 Medical Ctr Blvd, #305
Webster, TX 77598
(281) 332-1397
11914 Astoria Boulevard, #325
Houston, TX 77089
(281) 484-2030
21700 Kingsland Blvd.
Katy, TX 77450
(281) 578-4815
AGE ______________
ADDRESS_____________________________________________________DATE
Rx
REFILLS--
3-3-11
Homatropine 5% 5ml
1 gtt tid OD
0
Jill Autry, O.D.
Zirgan™ (ganciclovir ophthalmic gel) 0.15%
•
•
•
•
•
•
Iritis
Corneal abrasions/RCE
Corneal foreign body removal
Post-operative pain
Phthsical pain
Mark Mayo, M.D.
Randy Reichle, O.D.
4415 Crenshaw Rd.
Pasadena, TX 77504
Phone (281)998-3333
Joe Johnson
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–
–
–
–
• Contraindicated in pain from angle closure
6565 West Loop South
Bellaire, TX 77401
Phone (713)797-1010
NAME
• Ocular pain uses are numerous
Developed for treatment of acute superficial herpetic keratitis
Designed to address tolerability concerns with other antivirals
First approved in France under the tradename Virgan in 1995
Has been approved in Europe for over 10 years
In clinical trials, compared to acyclovir (ACV) 3% ointment
Double-masked studies not possible due to formulations—
Ganciclovir is a gel and acyclovir is an ointment
• To date there have been no clinical trials conducted to compare
Ganciclovir to trifluridine (TFT).
HERPES
• SIMPLEX
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–
–
–
–
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Unilateral
Recurrences in same eye
Dendrites or stellate epithelial lesions
Won’t always have follicles
Treat with Viroptic or with oral antivirals
When no longer staining, stop antiviral unless
stromal disease
– Stromal disease will need antiviral + steroid
Ulcer Healing Following Zirgan™ Use
Cornea after treatment with
Zirgan
Dendritic ulceration before
treatment with Zirgan™
54
9
Summary of Differences: Zirgan™ Compared to
Viroptic® (trifluridine ophthalmic solution) 1%
Dosage Frequency
Zirgan
Trifluridine
Instill 1 drop in the affected
eye 5 times per day until
corneal ulcer heals and then 1
drop 3 times per day for 7
days
Instill 1 drop Viroptic
Ophthalmic Solution, 1% onto
the cornea of the affected eye
every 2 hours while awake for a
maximum daily dosage of 9
drops until the cornea ulcer has
completely re-epithelialized.
Following re-epithelialization,
treatment for an additional 7 days
of 1 drop every 4 hours while
awake for minimum daily dosage
of 5 drops is recommended.
Please see full prescribing information for Zirgan® provided at this presentation
Viroptic is a registered trademark of Monarch Pharmaceuticals
HERPES SIMPLEX AND
ORAL ANTIVIRALS
• In place of Viroptic® topically
– 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
55
HERPES
ORAL ANTIVIRALS
• ZOSTER
– Unilateral in older patient
– With same-sided, vesicular facial lesions
– Lesions on tip of nose suggestive of impending
or current ocular involvement
– Conjunctivitis/iritis/corneal pseudodendrites
• May appear before skin lesions
– Start steroid q2h to qid ONLY IF
COMPLETELY NECESSARY
– Viroptic/Zirgan not used in Zoster
Edward Wade, M.D.
Chris Allee, O.D.
Ting Fang-Suarez, M.D.
Jill Autry, O.D.
Mark Mayo, M.D.
Randy Reichle, O.D.
6565 West Loop South
Bellaire, TX 77401
Phone (713)797-1010
4415 Crenshaw Rd.
Pasadena, TX 77504
Phone (281)998-3333
15400 SW Frwy
Sugar Land, TX 77478
(281)277-1010
450 Medical Ctr Blvd, #305
Webster, TX 77598
(281) 332-1397
11914 Astoria Boulevard, #325
Houston, TX 77089
(281) 484-2030
21700 Kingsland Blvd.
Katy, TX 77450
(281) 578-4815
NAME
Joe Johnson
AGE ______________
• 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
OTHER USES FOR
GLAUCOMA DROPS
• May be helpful with Fuch’s patients
– Avoid CAIs
• Stabilizing visual acuity/Rx in RK patients
ADDRESS_____________________________________________________DATE
Rx
REFILLS--
3-3-11
Acyclovir 800mg #50
1 po 5x day
0
– Especially prostaglandins given duration of action
• Brimonidine can
– Decrease pupil size to eliminate glare
– Decrease hyperemia
– Lacks side effects of pilocarpine
Jill Autry, O.D.
10
TOPAMAX INDUCED
ANGLE CLOSURE
ACUTE MYOPIA
• Topamax
Up to 6-8 diopters
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)
• 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
LATISSE®
Bimatoprost
Eyelash Growth Mechanism of
Action
–
–
–
–
Growing (Anagen
follicle)
Stimulates transition
from telogen to anagen
telogen
hair
falls out
catagen
anagen
Hair shaft
Prolongs
anagen
Dermal
papilla
Bul
b
Matrix
64
Primary Endpoint Highly
Statistically Significant
Treatment Application
Bimatoprost-treated subject
% of Subjects With at Least a 1-Grade
Improvement in GEA from Baseline
– One drop applied to a single-useper-eye applicator
– Applied daily to upper eyelid
margin
at the base of the eyelashes
78.1%* 78.6%*
69.3%*
50.4%*
GEA Score 2 (Moderate) baseline
P=0.07
P=0.2
14.6%
5.1%
GEA Score 3 (Marked) Wk 16
Week
65
* p<0.0001
66
11
FLOMAX
• Benign Prostatic Hypertrophy (BPH)
• Can cause miosis, prolapse, excessive movement,
PC rupture during cataract surgery
• Pre-op atropine or intraoperative alpha agonists
may help
• Notice how pupil dilates in office
• Discontinue before referral; however, may not
stop the syndrome
12