Dermatologic Therapy-Topical

1
My Top 10 Favorite Oral Drugs
John A. McGreal Jr., O.D. St. Louis, MO

2
Fexofenadine

• Antihistamines
• 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

3
Doxycycline

• Antibiotic old and not very good for staph or
  strep
• Long acting
• 20, 50, 75, 100mg capsules
• Excellent for meibomian gland dysfunction,
  blepharitis, ocular acne rosacea
• Useful in minimizing structural damage from
  collagenase in cases of chemical burns, severe
  infectious ulcers, RCE
• Dosages 20, 50,75, 100mg PO bid
• Rosacea 100mg bid X 1 mos, then 100mg qd X 2 mos
• Available as Doxycycline, Vibramycin, Alodox,
  NutriDox

4
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
• Anterior or posterior blepharaits patienyts have
  bacterial overgrowth on thei eyelids
• Anterior greasy skin flakes on lashes and
  inflammation on the anterior lid margin
• Posterior overgrowth results in sandy gritty
  irritation in morning

5
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
• 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

6
Blepharitis Therapy Topical/Oral

• NutriDox Convenience Kit
• Doxycycline 75mg tablets
• Works synergistically with SteriLid to reduce
  bacterial colonization
• Works synergistically with Theratears Nutrition
  to suppress inflammation
• 30 tablets of antibiotic
• TheraTears Nutrition omega-3 softgels (90)
• Thins meibomian secretions and reduces
  inflammation
• iHeat Warm Compress System
• iHeat Mask
• iHeat Warming Units (10)
• Activated by pressing on them, maintains heat for
  5 mins
• Indications Moderate-severe posterior
  blepharitis

7
Blepharitis Therapy Topical/Oral

• ALODOX Convenience Kit
• Doxycycline 20mg (low dose) tablets
• Below antimicrobial level, safer for prolonged
  use
• Sustains collagenolytic activity, reducing
  inflammation
• 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
• 25.00 rebate
• Assistance program through www.rxhope.com

8
Cephalexin

• Action cephalosporin
• Gram positives, skin skin structures
• Dosage
• 1-4g/D
• 250mg qid,
• 500mg bid, tid, qid,
• 750mg bid
• Contraindication PCN allergy
• Side effects - min
• Available as Keflex, Keftab, Keflet

9
Erythromycin

• 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
• Erythromycin ethylsuccinate (EES 400mg qid)
• Erythromycin particles (PCE Dispertab 333mg tid,
  500mg bid)
• Erythromycin delayed (ERYC 250mg qid)
• Available as Ilotycin ophthalmic ointment

10
Azithromycin

• Macrolide
• 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
• Zithromax Z-Pak, Zithromax TRI PAK, ZMAX, AzaSite
  topical
• Simple, convenient, effective

11
Acyclovir

• Antiviral for simplex, zoster chickenpox
• Dose form 200, 400, 800mg tablets, 200mg/5ml
• 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)
• Children over 40kg receive adult dose
• Herpes Zoster 800mg- 5x/D x 10D (initiate within
  72h, 48h best)
• Expensive
• Side effects nausea, diarrhea
• Only caution is with renal impairment
• Available as Zovirax

12
Methylprednisolone

• Oral corticosteroid
• Indications Allergic reactions, dermatologic
  reactions, stubborn iritis witch is slow to
  respond to intensive topical steroids, Bells
  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)

13
Types of Analgesics

• Narcotic analgesics
• 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
• Clinical stratification of pain
• Mild to moderate pain
• Moderate to severe pain
• Most severe

14
Narcotic Analgesics

• Side effects
• CNS
• Sedation, lightheadedness, dizziness, drowsiness,
  euphoria
• GI
• Nausea, vomiting, constipation
• Respiratory depression
• Contraindications
• Hypersensitivity to narcotics
• Respiratory disease
• Kidney or liver diseases

15
Oral Narcotic Analgesic - Guidelines

• Prescribing hints
• Never exceed maximum recommended amounts
• ASA - 8g/D
• APAP - 4g/D
• Ibuprofen - 1200mg/D OTC 2400mg/D Rx
• Codeine - 360mg/D
• All have abuse potential
• Precautions
• No EtOH
• Do not operate machinery

16
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

17
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
• RICE rest, ice, compression, elevation
• Mydriatic / cycloplegia useful with ciliary
  ocular pain
• Bandage contact lenses or pressure patches for
  epithelial defects

18
Codeine

• APAP / Codeine 15, 30, 60mg (Tylenol 2, 3, 4)
• ASA / Codeine 15, 30, 60mg (Empirin 2, 3, 4)
• Schedule III
• Side effects
• Lightheadedness, dizziness, sedation, nausea,
  vomiting, euphoria, constipation
• Pediatric dose 0.5mg/kg/day
• 3-6 yrs 5ml tid-qid (1 teaspoon)
• 7-12 yrs 10ml tid-qid (2 teaspoons)

19
Hydrocodone

• Actions narcotic analgesic and anti-tussive
• Combination with acetaminophen mostly, some
  ibuprofen
• Uses
• Moderate moderately severe pain
• Cautious use in elderly debilitated patients with
  renal or hepatic problems
• Dose q4-6h
• Available as Vicodin 5mg/500mg

20
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
• 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

21
Acetazolamide

• Oral CAI with attendant side effects
• 250mg, 500mg sequels (time released)
• Dosage qid for 250mg, 500 bid for sequels
• Sequels best for reduced side effects in long
  term chronic use but never use sequels for acute
  glaucoma
• Side effects paresthesias of fingers and lips,
  acid-base shifts, urinary calculi, impotence,
  thrombocytopenia, hypokalemia
• 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

22
EyePromise Restor

• Oral supplement for macular degeneration and at
  risk groups
• Improves MPOD over 6-12 months, reduces glare,
  improves contrast sensitivity
• Beneficial for dry eye, cataracts and wellness
  along with multivitamins
• Ingredients
• No beta-carotene or vitamin A
• Vitamin C
• Vitamin E
• Zinc
• Lutein
• Zeaxanthin
• Omega-3s
• Alpha-linoleic acid

23
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

24
Macular Pigment Studies

• Optom 2008 79266-272 Lueng
• Optometrist play key role in assessment
  monitoring risk of AMD
• LAST Study (Lutein Antioxidant Supplement Trial)
• 12 month study
• 90 male VA patients
• Lutein 10mg vs Lutein 10mg MV vs Placebo
• Lutein only or combination increases MPOD by
  gt50, Glare recovery, contrast sensitivity and
  visual acuity

25
Macular Pigment Studies

• OptomVisScience 2008 Stringham Hammond
• 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
• Higher intake of L/Zx reduced risk of AMD
• Confirmed protective benefit of zinc
• Higher beta carotene increased risk AMD

26
Macular Pigment Studies in Cataracts

• ArchOphthal 2008 Mueller et al
• CAREDS/WHI
• N1802 women with highest levels of L/Zx had 32
  lower incidence of NSC
• Ophthal 2008 115(8) Sperduto et al
• NEI Trial of Centrum Silver
• N1020 18 less lens events
• AmJClinNut 2008 Tan et al Blue Mountain Group
• N2464 Vit C and dietary antioxidants decreased
  NSC 50

27
Macular Pigment Studies in Diabetes

• IOVS 2008 Gierhardt et al
• Proved Zx mechanism of protection in early DR
• Anti-inflammatory VEGF regulation
• CAREDS 2007 Diabetic women have 30 lower MPOD
• Graetes 2008 Spanish Group
• Fed diabetic rats lutein and found it to be as
  effective as insulin at preventing cataract

28
Nutritionals

• EyePromise (ZeaVision)
• Zeaxanthin 8mg
• in the same 21 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

29
Cardiovascular Prevention

• Bonus Round

30
Oral NSAID - Aspirin

• Aspirin (ASA) salicylic acid derivative
• 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
• 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)

31
Oral NSAIDs

• Aspirin (ASA) salicylic acid derivative
• Aspirin (generic) 325mg, 81mg (low dose) as daily
  prohylactic for at risk groups
• Bayer 325mg
• Empirin 325mg
• Ecotrin 325mg
• Enteric coated
• Ascriptin 325mg
• Coated, buffered
• Bufferin 325mg
• Coated, buffered

32
Oral NSAIDs

• Aspirin (ASA) salicylic acid derivative
• 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
• Butalbital/ASA/Caffeine
• Butalbital/ASA/Caffeine/Codeine

33
Oral NSAIDs

• Aspirin (ASA) non-narcotic combinations
• Anacin caplets Aspirin 400 / Caffeine 32
• Anacin (max) Aspirin 500 / Caffeine 32
• BC Powder Aspirin 650 / Caffeine 32 /
  Salicylamide 195

34
Thrombolytics for MI

• Acute Coronary Syndromes
• Reteplace (Retavase)
• Eptifibatide (Integrilin)
• Tirofiban (Aggrastat)
• ASA (Bayer) 325mg chewed STAT
• Drug-eluting or bare metal stents
• Prevention
• 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

35
Thank you
McGreal Educational Institute
An educational affiliate of Missouri Eye
Associates