ORAL MEDS AND THE EYE
Jill Autry, OD, RPh
Eye Center of Texas, Houston
drjillautry@tropicalce.com
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
AGE
ADDRESS_____________________________________________________DATE
Rx
REFILLS--
NON-CONTROLLED Rx
• Doctor name/address/telephone #
• Patient name
• Address
– Added by pharmacist
• Patient age
– Usually only put if pediatric Rx
• Date
– Good for one year from date of issue
•
•
•
•
Drug info area
Refill line
Signature line
Some states require NPI number on all scripts (NJ)
CONTROLLED SUBSTANCE Rx
• Doctor name/address/telephone #
• Patient name
• Address
– Added by pharmacist
• Patient age
– Usually only put if pediatric Rx
• Date
– Good for six months from date of issue
• Drug info area
• Refill line
– Schedules III and IV allow 5 refills within 6 months of issue
• Signature line
• DEA number
– Some states require DPS (TX) or NPI number as well
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 ______________
ADDRESS_____________________________________________________DATE
Rx
REFILLS--
3-3-09
Combigan 10ml
1 gtt bid OU
3
Jill Autry, O.D.
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 ______________
ADDRESS_____________________________________________________DATE
Rx
REFILLS--
3-3-09
Keflex 500mg #20
1 po bid until gone
0
Jill Autry, O.D.
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 ______________
ADDRESS_____________________________________________________DATE
Rx
REFILLS--
3-3-09
Doxycycline 50mg #60
1 po bid with food
0
Jill Autry, O.D.
PRESCRIBING GUIDELINES
• Do not have to write “Sig.”…
• Do not have to write “po”
• Do not have to know if available in capsules
vs. tablets
• Can put more than one medication on the same
Rx pad (except controls)
• Write “Brand Name Medically Necessary”
when a generic is not desired
• Otherwise, generic is mandated
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 ______________
ADDRESS_____________________________________________________DATE
Rx
3-3-09
Pred Forte 1%, 10ml
1 gtt q2h OD-Shake Well
Brand Name Medically Necessary
REFILLS--
zero
Jill Autry, O.D.
Edward C. Wade, M.D.
Chris Allee, O.D.
Jill Autry, O.D.
Ting Fang-Suarez, M.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
-------------------------------------------------------------------------------------------------------------------------NAME
Steven Michaels
AGE
ADDRESS_____________________________________________________DATE 05-30-2008
Rx
REFILLS--ZERO
Phenergan 25mg #20
1 po q4-6h prn N & V
Jill Autry, O.D.
ABBREVIATIONS
•
•
•
•
•
•
•
qd-daily
bid-twice daily
tid-three times daily
qid-four times daily
qod-every other day
5X daily
9X daily
•
•
•
•
•
•
gtt-drop
ung-ointment
po-by mouth
IV-intravenous
IM-intramuscular
SQ-subcutaneous
ABBREVIATIONS
•
•
•
•
•
•
•
•
wc-with food
tud-take as directed
ud-as directed
ac-before meals
pc-after meals
qhs-every bedtime
prn-as needed for
UAT-until all taken
• achs-before meals and
at bedtime
• sx-surgery
• tx-treatment/therapy
• NKDA-no known drug
allergies
• N/V-nausea & vomiting
MEASUREMENTS
•
•
•
•
•
•
•
mg-milligram
kg-kilogram
1 kg=2.2 lb
1cc=1ml
1 tsp=5 ml
1 tbsp=15 ml
1 ml=20 drops
Before you prescribe…
• Allergic to anything?
• What other meds are they taking?
– Rx
– OTC
– Vitamins/Herbals
• What systemic conditions do they have?
– Especially note hepatic and renal problems.
Before you prescribe…
• Do they need it?
• Pregnant? Nursing? Trying?
• Age and weight of child?
– 12 yo=Adult in most cases
– Check drug monograph for dosing
• 1 kg=2.2 lbs
PAYING FOR MEDICATIONS
• Have prescription insurance?
• Consider generic availability for self-pay.
– Often in multiple daily dosages
– Decreases compliance
• 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
Edward C. Wade, M.D.
Chris Allee, O.D.
Jill Autry, O.D.
Ting Fang-Suarez, M.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
-------------------------------------------------------------------------------------------------------------------------NAME
Steven Michaels
AGE
ADDRESS_____________________________________________________DATE 05-30-2008
Rx
REFILLS--ZERO
Combigan 5ml
1 gtt bid OU
Dispense 90 day supply
Jill Autry, O.D.
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
INDIGENT PROGRAMS
• Allergan (Lumigan, Alphagan, Restasis)
– 1-800-553-6783
• Alcon (Azopt, Travatan, Betoptic S)
– 1-800-222-8103
PRESCRIBING FOR WOMEN
• Pregnant/nursing or thinking about it?
– Consult OB-GYN if necessary
– OK in pregnancy
• Augmentin, erythromycin, Zpack,
amoxicillin
• Tylenol #3, Vicodin
• Prednisone (oral and topical) when
necessary
• Acyclovir and other oral antivirals
PRESCRIBING FOR WOMEN
• On birth control pills?
– Counsel and document for concomitant antibiotic
therapy-controversial if true interaction exists
• No doxycycline during pregnancy/breast feeding
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 EXAMPLE
•
•
•
•
•
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
AUGMENTIN
PEDIATRIC INFO
• 20-40 mg/kg/day of amoxicillin in divided
doses every 8-12 hours
• If patient weighs 88 lb. or more, dose as
adult
• 125mg and 250mg/5ml suspensions
– Dose 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
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
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
READY TO PRESCRIBE
• Prescribe 250mg/5ml; 1 tsp q8h
• #150ml gives 10 day course
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
Morgan Smith
AGE ___5__
ADDRESS_____________________________________________________DATE
Rx
REFILLS--
3-3-10
Augmentin 250/5
1 tsp q8h x 10 days #150
0
Jill Autry, O.D.
ORAL ANTIBIOTICS
•
•
•
•
Is an oral antibiotic truly needed?
Check allergy information
Use less expensive antibiotics when possible
Consider covering for Haemophilus
influenzae in pediatric patients
– Less Hflu since Hib vaccine became widespread
• Take full course of therapy
OCULAR ANTIBIOTIC USES
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•
•
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Preseptal cellulitis
Dacryocystitis
Dacryoadenitis
Canaliculitis
Chlamydia
Dry eye/posterior blepharitis/ocular rosacea
Posterior toxoplasmosis activation
Endophthalmitis prevention
ALLERGIC REACTIONS
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Hypersensitivity reaction mediated by IgE
5-10% of all adverse drug reactions
Skin rash, hives, or itching
Wheezing or trouble breathing
Swelling of the face, lips, or throat
Nausea, vomiting, diarrhea
Discontinue use immediately; Consult physician
Severe reactions demand emergency care
ORAL ANTIBIOTICS
• Controversial whether antibiotics and birth
control truly interact-still counsel and
document
• Can cause thrush, vaginal yeast infections
– Take doses with yogurt
• Stop antibiotic if patient reports severe
diarrhea/blood in stool
– Concerns of pseudomembranous colitis
AMOXICILLIN
• 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
AMOXICILLIN DOSAGE
• Skin and soft tissue infections
• Adults
– 875mg q12h
• Children
– 20-40mg/kg/day divided q8h
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--
3-3-09
Amoxicillin 875
1 po bid x 10 days #20
0
Jill Autry, O.D.
AUGMENTIN
• 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
AUGMENTIN INFO
•
•
•
•
•
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)
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--
3-3-09
Augmentin 875mg
1 po bid x 10 days #20
0
Jill Autry, O.D.
CEPHALOSPORINS
• 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)
CEPHALEXIN
•
•
•
•
•
•
Brand name KEFLEX®
First generation cephalosporin
Good gram positive coverage (Staph/Strep)
Cheap
Adult dose is 500mg bid
Also available in suspension for children
– 20-40mg/kg/day divided q8h
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--
3-3-09
Keflex 500mg
1 po bid UAT #20
0
Jill Autry, O.D.
ALLERGIC TO PENICILLIN?
• 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
MACROLIDES
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•
•
•
•
Inhibit bacterial protein synthesis
Erythromycin, clarithromycin, azithromycin
Use with caution in liver disease
Drug interactions increased (next slide)
Great for penicillin allergic patients
SELECT MACROLIDE
DRUG INTERACTIONS
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Theophylline (asthma, COPD)
Dilantin, Tegretol, Depakote (epilepsy)
Digoxin (Congestive heart failure)
Coumadin (anticoagulant)
Zocor, Mevacor, Lipitor (cholesterol)
Norpace (antiarrythmic)
Many antiretroviral (HIV) medications
Ergot derivatives (migraines)
ZITHROMAX
(Azithromycin)
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•
•
•
•
•
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
ZITHROMAX
• 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
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--
3-3-09
Zpak
0
Jill Autry, O.D.
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--
3-3-09
Zithromax 250mg #4
Take 4 pills all at once
0
Jill Autry, O.D.
-CYCLINES
•
•
•
•
•
•
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
DOXYCYCLINE
•
•
•
•
•
•
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
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--
3-3-09
Doxycycline 50mg
1 po bid #60
Take with food
0
Jill Autry, O.D.
OCULAR USES
• Antibiotic use
– 100mg bid x 10 days
• Posterior bleph and Dry eye
– 50mg bid x 4-6 weeks then
– 50mg qd x 3-6 months or indefinitely
FLUOROQUINOLONES
• 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
FLUOROQUINOLONES
• 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 interactions (next slide)
Musculoskeletal side effects
– Arthralgia, tendonitis, tendon rupture
FLUOROQUINOLONE DRUG
INTERACTIONS
• Antacids/vitamins
– Wait 2 hours before or 3 hours after
• Caffeine
– Wait 2 hours before or 2 hours after
•
•
•
•
Warfarin (Coumadin™)
Insulin
Oral antidiabetic medications
Theophylline
FLUOROQUINOLONE
VITREOUS PENETRATION
• Intraocular foreign bodies/penetrating
trauma
• Pre-op prophylaxis for health care workers
• Bleb-associated endophthalmitis
• Avelox® (oral moxifloxacin)
– 400 mg qd
– Preferred over Cipro® due to increased coverage of
gram positive organisms and less resistance
– Also consider Levaquin 500mg qd
Edward C. Wade, M.D.
Chris Allee, O.D.
Jill Autry, O.D.
Ting Fang-Suarez, M.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
-------------------------------------------------------------------------------------------------------------------------NAME
Steven Michaels
AGE
ADDRESS_____________________________________________________DATE 05-30-2008
Rx
REFILLS--ZERO
Avelox 400mg
1 po qd #7
Jill Autry, O.D.
LEVAQUIN
• 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
DRY EYE ORAL AGENTS
• Salagen® (oral pilocarpine HCl)
– 5 mg qid for dry mouth
• Evoxac®
– 30 mg tid for dry mouth
• Oral meds approved for dry mouth
associated with Sjogren’s patients and
head/neck radiation
• Can consider for DES
DIAMOX
(Acetazolamide)
• 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
DIAMOX
(Acetazolamide)
•
•
•
•
•
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”
DIAMOX
(Acetazolamide)
• 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
DIAMOX
(Acetazolamide)
•
•
•
•
Treatment of pseudotumor cerebri
Need CBC with differential as baseline
Start 500mg sequels bid
Often results in tingling, “pins and needles”
in extremities
– Can lower dose to 250mg bid
– Can try Neptazane 50mg tid
DIAMOX SIDE EFFECTS
•
•
•
•
•
•
•
•
Rare with short term use
Paresthesias (“pins and needles”)
Kidney stones
Acute respiratory failure
Acid-base imbalances
Blood dyscrasias (aplastic anemia)
Induced myopia
Metallic taste
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
®
OSMOGLYN
•
•
•
•
•
•
Glycerin 50% oral solution
An osmotic diuretic
Decreases IOP quickly; but lasts only 1-2 hrs
1-2 g/kg orally for initial dose
Avoid in diabetics due to high caloric load
Risk of dehydration in elderly and those with
kidney disease
• Causes nausea and vomiting
• Worsens congestive heart failure
PAIN CONTROL
• 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
CODEINE
•
•
•
•
•
•
•
Naturally occurring substance
From the opium poppy
1/12 the strength of morphine
Rarely used alone
Tylenol #3® (APAP and codeine)
Empirin #3® (ASA and codeine)
Also used as an antitussive in cough syrups
CODEINE COMBINATIONS
• Tylenol #3® and Tylenol® #4
• Increasing codeine amount from #3 to #4
• APAP amount is 325mg in each
• #3-30mg codeine + 325mg APAP
• #4-60mg codeine + 325mg APAP
• Tylenol with codeine® elixir is APAP
120mg/5cc with 12mg codeine/5cc
TYLENOL #3
•
•
•
•
•
•
•
Schedule III
Central acting narcotic analgesic
325mg acetaminophen + 30mg codeine
Avoid in liver disease/alcoholism
No extra Tylenol® in addition
No alcohol
GI distress and sedation are main side effects
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 6565 Golden River Drive, Houston, TX 77082
Rx
REFILLS--
DATE 3-3-09
Tylenol #3 #20 (twenty)
1-2 po q4-6h prn pain
zero
Jill Autry, O.D.
MA0123456
ALLERGIC TO CODEINE?
• Most internists still use hydrocodone
because it is a synthetic form of codeine
• Most codeine “allergies” are just GI side
effects
• True IgE mediated allergic reaction low
HYDROCODONE
COMBINATIONS
• As effective as Class II narcotics but with
Class III status
• Significantly more pain relief and duration
of action compared to codeine
• Induces euphoria
• Highly addictive
• Also has antitussive properties
HYDROCODONE PRODUCTS
• 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
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 6565 Golden River Drive, Houston, TX 77082
Rx
REFILLS--
DATE 3-3-09
Vicodin 5/500 #30 (thirty)
1-2 q4-6h prn pain
zero
Jill Autry, O.D.
MA0123456
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 6565 Golden River Drive, Houston, TX 77082
Rx
REFILLS--
DATE 3-3-09
Vicodin ES #30 (thirty)
1 q4h-6h prn pain
zero
Jill Autry, O.D.
MA0123456
SIDE EFFECTS OF PAIN MEDS
•
•
•
•
•
•
•
Constipation
Nausea and vomiting
Sedation
Dizziness
Itching
Respiratory depression
Addiction
APAP & LIVER FAILURE
• 42% of acute liver failure cases in the US result
from acetaminophen-induced toxicity
• Of those who overdosed unintentionally, 62%
were using opioid-containing compounds
• Most commonly hydrocodone/APAP
combinations
• Counsel patients concerning amount of APAP in
prescribed medication
• Avoid additive APAP alone or in combination
products such as cough and cold remedies
GETTING A DEA NUMBER
•
•
•
•
•
•
•
On-line application
www.deadiversion.usdoj.gov
Optometrists are mid-level practitioners (MLP)
First time applicant-Form 224
Renewal-Form 224a
Cost $551/Good for 3 years
Takes around 1-3 months to receive
ALSO CONSIDER
•
•
•
•
•
®
ULTRAM
Tramadol (Ultram®) 50 mg tablets
NOT A CONTROLLED SUBSTANCE
1-2 q4-6h prn pain
Central acting synthetic opioid analgesic
Also inhibits serotonin and norepinephrine
reuptake
• Similar in efficacy to Tylenol #3
• Similar side effect profile and addiction profile
• Controversial in opioid allergy
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
DATE 3-3-09
ADDRESS
Rx
REFILLS--
AGE ________
Ultram 50mg #30 (thirty)
1 q4-6h prn pain
zero
Jill Autry, O.D.
ORAL ANTIHISTAMINES
• Central acting antihistamines
– Benadryl (diphenhydramine)
•
Peripherally acting antihistamines
–
–
–
–
–
–
Selective peripheral histamine H1 receptor blockade
Less CNS and anticholinergic effects
Less sedating but also less effective
Claritin, Allegra, Zyrtec
All available with and without a decongestant
Zyrtec and Claritin available OTC
MY FIRST CHOICE
• ZYRTEC®
• Non-sedating antihistamine
• Less ocular surface damage
– When compared to Claritin®
– Still avoid in dry eye if possible
• Less drug interactions
• Less expensive
ZYRTEC
(Cetirizine)
• Adult dosage: 10mg qd
• Pediatric >5 yo: 5-10 mg qd, 2-5 yo: 2.55mg qd
• Can be used down to 6 months of age
• Comes in 5mg, 10mg, and 1mg/ml syrup
• w/o regard to food
• Available with and without a decongestant
ORAL ANTIVIRALS
• Inhibit viral DNA polymerase without
inhibiting normal cellular activity
• Well tolerated and safe
• Decrease dosage in renal disease
• All 3 drugs similar in efficacy--not in price
– Acyclovir 7 day course
– Famvir 7 day course
– Valtrex 7 day course
= $35.78
= $237.88
= $243.36
ORAL ANTIVIRALS
• 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 Pred Forte® 1%
• Cover steroid with Viroptic®/Zirgan® or
oral antiviral
ORAL ANTIVIRALS
• 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
ORAL ANTIVIRALS
• 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
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 ______________
ADDRESS_____________________________________________________DATE
Rx
REFILLS--
3-3-09
Acyclovir 800mg #50
1 po 5x day
0
Jill Autry, O.D.
INFLAMMATION
•
•
•
•
•
•
Prostaglandin formation
Cyclo-oxygenase pathway
Inhibited by NSAIDs, aspirin
Reduce pain
Reduce inflammation
Reduce edema
ORAL STEROID USES
•
•
•
•
•
Allergic reaction
Anterior uveitis
Posterior uveitis
Scleritis
Arteritic ischemic optic neuropathy
– “Giant Cell”
•
•
•
•
Optic neuritis
Orbital pseudotumor
Herpes zoster
Other optic neuropathies
ORAL STEROIDS
• 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
• Consider Medrol Dosepak
– For allergic reactions, zoster, anterior uveitis
– Less serious inflammations
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 ______________
ADDRESS_____________________________________________________DATE
Rx
REFILLS--
3-3-09
Prednisone 20mg #30
3 tabs (60mg) qd with food/milk
0
Jill Autry, O.D.
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 ______________
ADDRESS_____________________________________________________DATE
Rx
REFILLS--
3-3-09
Medrol Dose Pack
TUD
0
Jill Autry, O.D.
ORAL STEROIDS
• Short-term usage rarely has ocular SE
• 5% of the general population will be steroid
responders
• 95% of glaucoma patients will be steroid
responders
• All steroids can increase IOP
– Topical, inhaled, nasal, oral, “soft steroids”
STEROID SIDE EFFECTS
• Increased intraocular pressure
– Topical will increase in 2-4 weeks
– Oral/IV can increase within 3-4 days
• Cataract
– Usually posterior subcapsular
•
•
•
•
Steroid induced diabetes/decrease control
Adrenal suppression
Reduced immunity/infections
Mood swings/erratic behavior
NSAIDS
• Ibuprofen (aka Motrin®, Advil®)
– 200mg available OTC
– Can double, triple, or quadruple OTC dose to get Rx
dosages
• Toradol® 10mg q6h
–
–
–
–
Starting 3 days before PRK can decrease pain
Use for 3 days post-op as well
Often avoid other controlled analgesics
5-6 day max usage recommended
Anti-Inflammatory Side Effects
• All NSAIDS have been associated with
inducing ulcers
– Consider Zantac® 150mg bid for extended
NSAID therapy
• All NSAIDS have been associated with
increased bleeding times
– Avoid in conditions of ocular hemorrhaging
– Recommend Tylenol® instead
ALLERGIC TO ASPIRIN?
• Triad leading to anaphylaxis
– Aspirin allergy
– Asthma
– Nasal polyps
• Avoid other non-steroidals such as
ibuprofen (Advil, Motrin)
• Avoid topical non-steroidals (Acular,
Xibrom, Nevanac)
ANTI-EMETIC
•
•
•
•
•
•
Phenergan 25mg tablets or suppositories
Phenergan 12.5mg tablets
Also available in syrup and elixir
1 every 4-6 hours as needed for N & V
Can cause increased sedation
Also consider Zofran 8mg q8h
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 ______________
ADDRESS_____________________________________________________DATE
Rx
REFILLS--
3-3-09
Phenergan 25mg #20
1 po q 4-6h prn NV
0
Jill Autry, O.D.
SLEEP AIDS
• Consider Diphendydramine 25-50mg
(Benadryl) available OTC
• Ambien 5mg or 10mg qhs prn
– Ambien CR 6.25mg or 12.5mg
– All Ambien products are Schedule IV
• Rozerem 8mg qhs prn
– Not a controlled substance
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 ______________
ADDRESS_____________________________________________________DATE
Rx
REFILLS--
3-3-09
Ambien CR 6.25mg #3 (three)
1 po qhs prn sleep
zero
Jill Autry, O.D.
MA0123456
DEALING WITH OTHER
PROFESSIONALS
• Pharmacists
• DEA numbers
• Calling in prescriptions
• Insurance companies
• Talking with PCP when necessary
KEEPING UP
• Rxlist.com
– Search for drug information
– Top 300 List
•
•
•
•
Centerwatch.com
Epocrates.com
Drugs.com
Lexi.com
– Order Drug Information Handbook Pocket yearly
– What’s New
• New Drug Section