oral meds and the eye jill autry, od, rph eye center of texas, houston drjillautry@tropicalce.com

ORAL MEDS AND THE EYE

Jill Autry, OD, RPh

Eye Center of Texas, Houston

drjillautry@tropicalce.com

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 FrwyBellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478Phone (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 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815

NAME AGE

ADDRESS_____________________________________________________DATE

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

NAME Joe Johnson AGE ______________

ADDRESS_____________________________________________________DATE 3-3-09

Rx Combigan 10ml 1 gtt bid OU

REFILLS-- 3 Jill Autry, O.D.

ADDRESS_____________________________________________________DATE 3-3-09

Rx Keflex 500mg #20 1 po bid until gone

ADDRESS_____________________________________________________DATE 3-3-09

Rx Doxycycline 50mg #60 1 po bid with food

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

ADDRESS_____________________________________________________DATE 3-3-09

Rx 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. Ting Fang-Suarez, M.D.Chris Allee, O.D. Randy Reichle, O.D.Jill Autry, O.D.

6565 West Loop South 4415 Crenshaw Rd. 15400 SW FrwyBellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478Phone (713)797-1010 Phone (281)998-3333 (281)277-1010--------------------------------------------------------------------------------------------------------------------------

NAME Steven Michaels AGE

ADDRESS_____________________________________________________DATE 05-30-2008

Rx Phenergan 25mg #201 po q4-6h prn N & V

REFILLS--ZERO 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

ADDRESS_____________________________________________________DATE 05-30-2008

Rx Combigan 5ml1 gtt bid OUDispense 90 day supply

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

READY TO PRESCRIBE

• Prescribe 250mg/5ml; 1 tsp q8h

• #150ml gives 10 day course

NAME Morgan Smith AGE ___5__

ADDRESS_____________________________________________________DATE 3-3-10

Rx Augmentin 250/5 1 tsp q8h x 10 days #150

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

• Preseptal cellulitis• Dacryocystitis• Dacryoadenitis• Canaliculitis• Chlamydia• Dry eye/posterior blepharitis/ocular rosacea• Posterior toxoplasmosis activation• Endophthalmitis prevention

ALLERGIC REACTIONS

• 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

NAME Jack Cooper AGE ________

ADDRESS_____________________________________________________DATE 3-3-09

Rx Amoxicillin 875 1 po bid x 10 days #20

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)

ADDRESS_____________________________________________________DATE 3-3-09

Rx Augmentin 875mg 1 po bid x 10 days #20

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

ADDRESS_____________________________________________________DATE 3-3-09

Rx Keflex 500mg 1 po bid UAT #20

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

• 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

• 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)

• 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

ADDRESS_____________________________________________________DATE 3-3-09

Rx Zpak

ADDRESS_____________________________________________________DATE 3-3-09

Rx Zithromax 250mg #4 Take 4 pills all at once

-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

ADDRESS_____________________________________________________DATE 3-3-09

Rx Doxycycline 50mg1 po bid #60Take with food

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

ADDRESS_____________________________________________________DATE 05-30-2008

Rx Avelox 400mg 1 po qd #7

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”

• 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

• 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

ADDRESS 6565 Golden River Drive, Houston, TX 77082 DATE 3-3-09

Rx Tylenol #3 #20 (twenty)1-2 po q4-6h prn pain

REFILLS-- 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

Rx Vicodin 5/500 #30 (thirty)1-2 q4-6h prn pain

Rx Vicodin ES #30 (thirty)1 q4h-6h prn pain

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

ADDRESS DATE 3-3-09

Rx Ultram 50mg #30 (thirty)1 q4-6h prn pain

REFILLS-- 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: 2.5-5mg 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 = $35.78– Famvir 7 day course = $237.88– Valtrex 7 day course = $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

ADDRESS_____________________________________________________DATE 3-3-09

Rx Acyclovir 800mg #501 po 5x day

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

ADDRESS_____________________________________________________DATE 3-3-09

Rx Prednisone 20mg #303 tabs (60mg) qd with food/milk

ADDRESS_____________________________________________________DATE 3-3-09

Rx Medrol Dose PackTUD

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

ADDRESS_____________________________________________________DATE 3-3-09

Rx Phenergan 25mg #201 po q 4-6h prn NV

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

ADDRESS_____________________________________________________DATE 3-3-09

Rx Ambien CR 6.25mg #3 (three)1 po qhs prn sleep

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

oral meds and the eye jill autry, od, rph eye center of texas, houston drjillautry@tropicalce.com

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