My Top 10 Favorite Oral
Drugs
John A. McGreal Jr., O.D.
St. Louis, MO
JAM
Fexofenadine
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Antihistamines
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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
 Allegra
60mg bid
 Allegra 180 qd
 Allegra-D 12hr (60/120) for nasal congestion
 Allegra-D 24hr (180/240) for nasal congestion
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Doxycycline
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Antibiotic – old and not very good for staph or strep
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Excellent for meibomian gland dysfunction, blepharitis, ocular
acne rosacea
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Useful in minimizing structural damage from collagenase in cases of
chemical burns, severe infectious ulcers, RCE
Dosages: 20, 50,75, 100mg PO bid
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Long acting
20, 50, 75, 100mg capsules
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 Care
Baby shampoo based scrubs dry out the eyelid skin &
remove antibacterial skin oils
 Scrubbing eyelid skin increases bacterial penetration
and colonization
 No shampoo based products have antibacterial effect
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Anterior or posterior blepharaits patienyts have bacterial
overgrowth on thei eyelids
– greasy skin flakes on lashes and inflammation on the
anterior lid margin
 Posterior – overgrowth results in sandy gritty irritation in morning
 Anterior
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New Ideas in Eyelid Care
Production of bacterial lipases and esterases hydrolyze
the wax and sterol esters in the meibum, creating free
fatty acids that irritate the eye and may promote
inflammation and resultant changes in tear film stability
 Dry eye patients also have bacterial overgrowth on their
eyelids
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This bacteria inhibits conjunctival goblet cells proliferation
in tissue culture, relative to normal controls
 Mucus
from these cell lubricates the ocular surface
 Dry eye patients already have decreased goblet cell density
secondary to increased tear film osmolarity
 Punctal plugs are covered in a biofilm colonized by a diversity of
organisms
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Blepharitis Therapy – Topical/Oral
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NutriDox Convenience Kit
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Doxycycline 75mg tablets
 Works
synergistically with SteriLid to reduce bacterial colonization
 Works synergistically with Theratears Nutrition to suppress
inflammation
 30 tablets of antibiotic
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TheraTears Nutrition omega-3 softgels (#90)
 Thins
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meibomian secretions and reduces inflammation
iHeat Warm Compress System
 iHeat
Mask
 iHeat Warming Units (#10)
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Activated by pressing on them, maintains heat for 5 mins
Indications: Moderate-severe posterior blepharitis
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Blepharitis Therapy – Topical/Oral
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ALODOX Convenience Kit
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Doxycycline 20mg (low dose) tablets
 Below
antimicrobial level, safer for prolonged use
 Sustains collagenolytic activity, reducing inflammation
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Ocusoft Lid Scrub Plus (Cynacon/Ocusoft)
1
box of pre-moistened pads
 60 tablets of antibiotic
 1 bottle of 50ml Ocusoft Lid Scrub Original Formula
 Covered by most insurances as tier 3 co-pay
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$25.00 rebate
Assistance program through www.rxhope.com
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Cephalexin
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Action – cephalosporin
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Gram positives, skin & skin structures
Dosage:
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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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Erythromycin
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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
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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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Azithromycin
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Macrolide
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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
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Zithromax Z-Pak, Zithromax TRI PAK, ZMAX, AzaSite topical
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Simple, convenient, effective
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Acyclovir
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Antiviral for simplex, zoster & chickenpox
Dose form – 200, 400, 800mg tablets, 200mg/5ml
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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)
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Children over 40kg receive adult dose
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Herpes Zoster: 800mg- 5x/D x 10D (initiate within 72h, 48h best)
Expensive
Side effects: nausea, diarrhea
Only caution is with renal impairment
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Available as Zovirax
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Methylprednisolone
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 Analgesics
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Narcotic analgesics
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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
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Clinical stratification of pain
 Mild
to moderate pain
 Moderate to severe pain
 Most severe
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Narcotic Analgesics
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Side effects
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CNS
 Sedation,
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GI
 Nausea,
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lightheadedness, dizziness, drowsiness, euphoria
vomiting, constipation
Respiratory depression
Contraindications
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Hypersensitivity to narcotics
Respiratory disease
Kidney or liver diseases
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Oral Narcotic Analgesic - Guidelines
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Prescribing hints
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Never exceed maximum recommended amounts
 ASA -
8g/D
 APAP - 4g/D
 Ibuprofen - 1200mg/D OTC & 2400mg/D Rx
 Codeine - 360mg/D
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All have abuse potential
Precautions
 No
EtOH
 Do not operate machinery
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Oral 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 - 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
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“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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Codeine
APAP / Codeine 15, 30, 60mg (Tylenol #2, 3, 4)
 ASA / Codeine 15, 30, 60mg (Empirin #2, 3, 4)
 Schedule III
 Side effects
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Lightheadedness, dizziness, sedation, nausea, vomiting,
euphoria, constipation
Pediatric dose – 0.5mg/kg/day
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3-6 yrs 5ml tid-qid (1 teaspoon)
7-12 yrs 10ml tid-qid (2 teaspoons)
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Hydrocodone
Actions – narcotic analgesic and anti-tussive
 Combination with acetaminophen mostly, some
ibuprofen
 Uses
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Moderate –moderately severe pain
Cautious use in elderly debilitated patients with renal or
hepatic problems
Dose q4-6h
 Available as Vicodin 5mg/500mg
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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
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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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Acetazolamide
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Oral CAI with attendant side effects
250mg, 500mg sequels (time released)
Dosage – qid for 250mg, 500 bid for sequels
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Side effects – paresthesias of fingers and lips, acid-base shifts,
urinary calculi, impotence, thrombocytopenia, hypokalemia
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Sequels best for reduced side effects in long term chronic use but never
use sequels for acute glaucoma
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 Restor
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Oral supplement for macular degeneration and at risk groups
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Improves MPOD over 6-12 months, reduces glare, improves contrast
sensitivity
Beneficial for dry eye, cataracts and wellness along with multivitamins
Ingredients
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No beta-carotene or vitamin A
Vitamin C
Vitamin E
Zinc
Lutein
Zeaxanthin
Omega-3s
Alpha-linoleic acid
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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 Studies
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Optom 2008; 79:266-272 Lueng
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Optometrist play key role in assessment & monitoring risk of
AMD
LAST Study (Lutein Antioxidant Supplement Trial)
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12 month study
90 male VA patients
 Lutein
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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 Studies
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OptomVisScience 2008; Stringham & Hammond
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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
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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 Cataracts
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ArchOphthal 2008; Mueller et al
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Ophthal 2008 115(8) Sperduto et al
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CAREDS/WHI
N=1802 women with highest levels of L/Zx had 32% lower
incidence of NSC
NEI Trial of Centrum Silver
N=1020 18% less lens events
AmJClinNut 2008; Tan et al Blue Mountain Group
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N=2464 Vit C and dietary antioxidants decreased NSC 50%
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Macular Pigment Studies in Diabetes
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IOVS 2008; Gierhardt et al
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Proved Zx mechanism of protection in early DR
 Anti-inflammatory
& VEGF regulation
CAREDS 2007 Diabetic women have 30% lower
MPOD
 Graetes 2008 Spanish Group
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Fed diabetic rats lutein and found it to be as effective as
insulin at preventing cataract
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Nutritionals
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EyePromise (ZeaVision)
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Zeaxanthin 8mg
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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
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Cardiovascular Prevention
Bonus Round
Oral NSAID - Aspirin
Aspirin (ASA) – salicylic acid derivative
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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
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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 NSAIDs
Aspirin (ASA) – salicylic acid derivative
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Aspirin (generic) 325mg, 81mg (low dose) as daily
prohylactic for at risk groups
Bayer 325mg
Empirin 325mg
Ecotrin 325mg
 Enteric
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Ascriptin 325mg
 Coated,
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coated
buffered
Bufferin 325mg
 Coated,
buffered
Oral NSAIDs
Aspirin (ASA) – salicylic acid derivative
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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
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Butalbital/ASA/Caffeine
Butalbital/ASA/Caffeine/Codeine
Oral NSAIDs
Aspirin (ASA) – non-narcotic combinations
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Anacin caplets
Anacin (max)
BC Powder
Aspirin 400 / Caffeine 32
Aspirin 500 / Caffeine 32
Aspirin 650 / Caffeine 32 / Salicylamide
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Thrombolytics for MI
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Acute Coronary Syndromes
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Reteplace (Retavase)
Eptifibatide (Integrilin)
Tirofiban (Aggrastat)
ASA (Bayer) 325mg chewed STAT
Drug-eluting or bare metal stents
Prevention
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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 you
McGreal Educational
Institute
An educational affiliate of Missouri Eye Associates
JAM