Jane Ann Grogg, O.D., F.A.A.O. Indiana University School of Optometry

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1 Jane Ann Grogg, O.D., F.A.A.O. Indiana University School of Optometry

2 Glaucoma Antibiotics Antiviral Allergy Anti-inflammatory Pain management Miscellaneous

4 My credentials Clinical experience Triage red eye clinic x 22 years Colleagues Disclosures

5 Oral antibiotics and eye care Indications Acute disease Chronic disease

6 Preseptal Cellulitis Symptoms pain, tenderness and redness in the periorbital area Signs erythema in the periorbital area Most often associated with hordeolum, very often they are not even visible, but the pain can be localized preauricular nodes

8 Classes of antibiotics to consider Penicillinace-resistant penicillin Broad-spectrum penicillin + β - lactamase inhibitor Cephalosporin Macrolide Quinolone Tetracyclines

9 Considerations. Efficacy Compliance Side effects Cost

10 Dicloxacillin For the treatment of preseptal cellulitis Penicillinase resistant penicillin 250 mg QID X 7-10 days 500 mg BID x 7-10 days Also an excellent choice for canaliculitis and dacryocystitis Side effects Cheap

11 Prescription writing 101

12 Jane Ann Grogg, O.D. 744 E. Third St., Bloomington, IN Lic # B NPI# xxxxxxxxxx Name of the drug and mg Disp: How much Sig: Instructions Dispense as written Jane Ann Grogg, O.D. Substitution permitted

13 Jane Ann Grogg, O.D. 744 E. Third St., Bloomington, IN Lic # B NPI# xxxxxxxxxx Dicloxacillin 500 mg Disp: # 14 Sig: i tab PO BID x 7 days Dispense as written Jane Ann Grogg, O.D. Substitution permitted

14 Check temperature No diplopia and minimal pain with eye movement

$cellulitis For prophylaxis in blow-out fractures Cheap (generic)$

16 Keflex Cephalexin A cephalosporin For the treatment of preseptal cellulitis For prophylaxis in blow-out fractures Cheap (generic)

17 Keflex/Cephalexin Category B in pregnancy Also affective in afebrile adults with dacryocystitis Cross sensitivity to penicillin s Precautions in renal dysfunction and GI disease (esp. colitis) Adverse reaction include GI upset, rash, fatigue, headache, blood dyscrasias, liver enzymes

18 500 mg BID x 7 days

19 Keflex 500 mg TID x 10 days

21 What s the scoop? Cross sensitivity to penicillin Pichichero, Cephalosporins can be prescribed safely for penicillin-allergic patients. J Fam Pract 2006 Feb; 55(2): Not ALL Depends upon the chemical side chain Different side chain: Ceftin, Vantin, Cefzil, Omincef Same side chain: Keflex, Duricef, Keflin, Ultracef, Cefazolin

22 Take home message: IgE-mediated reactions (such as anaphylaxis, hypotension, laryngeal edema, wheezing, angioedema, urticaria) to PCN: Avoid cephalosporins with similar side chain: Keflex, Duricef, Keflin, Ultracef, Cefazolin You may give cephalosporins that have different side chains: Ceftin, Vantin, Cefzil, Omincef You may use cephalosporins for non-ige mediated adverse reactions: non-pruritic, non-urticarial maculopapular rash

$PCN allergy Chlamydia Sinusitis In association with bacterial conjunctivitis Coverage for blow-out fractures Ocular pain Consider$

23 Azithromycin A macrolide Category B in pregnancy Affordable (~$35) 250mg, 500 mg, 1 g packet Common uses Soft tissue infection : esp with PCN allergy Chlamydia Sinusitis In association with bacterial conjunctivitis Coverage for blow-out fractures Ocular pain Consider sinusitis

24 Adverse reactions Generally well tolerated GI (take same time of day) HA, CNS disturbances Adjust dose if renal impairment

25 Traditional Z-Pak : Take mg tab on day one, followed by mg tab days 2-5 Skin and skin structure take as directed Tri-pak: mg tab for 3 days Sinusitis

26 soft tissue skin and skin structure infection: Duricef (cephalosporin) 500 mg BID or 1 g QD Now generically available 1gm x 7days=$15 Precaution in penicillin or other allergy Augmentum PCN + β lactamase inhibitor (clavulanate acid) 875 mg BID x 7 days Contraindicated in PCN allergy Levaquin Quinolone 500 qd x 7 days

27 Patient is allergic to PCN.

28 Jane Ann Grogg, O.D. 744 E. Third St., Bloomington, IN Lic # B NPI# xxxxxxxxxx Azithromycin Tri-Pak Take as directed Dispense as written Jane Ann Grogg, O.D. Substitution permitted

30 Pink eye x 3 weeks Ocular Symptoms

31 Chlamydia Treatment Treatment of choice Azithromycin 1 gram dose 250 mg, disp #4 500 mg, disp #2 Powder ($40) Treat partners Referral for other STD testing, analysis, counseling Health Department forms

32 Azithromycin Disp: 1 gram packet Sig: take as directed Jane Ann Grogg, O.D. 744 E. Third St., Bloomington, IN Lic # B NPI# xxxxxxxxxx Dispense as written Jane Ann Grogg, O.D. Substitution permitted

33 MRSA considerations: Septra or Bactrim Trimethoprim and Sulfamethoxazole Contraindicated in sulfa allergies Avelox Quinolone $ Zyvox $$$ linezolid Doxycycline Clindamycin Vancomycin*

34 Meibomianitis AKA post. blepharitis, ocular rosacea Symptoms: Chronic burning, irritation, redness Symptoms>>>>>Signs Signs: MGD, chronic conjunctivitis, acne rosacea, telangectatic vessels, tylosis, pannus

35 Choosing a medication Chronic medication for chronic conditions Importance of long term use

The Tetracyclines Indications MGD posterior blepharitis acne rosacea phlyctenular keratoconjunctivitis recurrent erosions: inhibit extracellular matrix

36 The Tetracyclines Indications MGD posterior blepharitis acne rosacea phlyctenular keratoconjunctivitis recurrent erosions: inhibit extracellular matrix metalloproteinases. The metalloproteinases are responsible for non-adhesion of the epithelium once it is traumatized old treatment chlamydia/reiter s syndrome Increased risk of PTC

37 Treatment options: The Tetracyclines Tetracycline X Doxycycline Minocycline

38 Doxycycline Drug of choice of the tetracyclines easier dosage less side effects COST Price increase of Hyclate version HCL for a period of time Temporary taken without regard to meals or dairy products

39 Monodox Doxycycline monohydrate 50 mg, 100 mg Dosage schedule 100mg initially 50 mg maintenance dose Take with food ( GI side effects) Don t take a bed time or prior to laying down

40 Precautions GI upset Sun exposure Pregnancy (cat.d)/ nursing Children Not recommended in children < 8 year of age

43 Dosage for Rosacea and MGD 100 mg BID X 2-4 weeks Taper to 100 qd x 1-3 months Consider further taper to 50 mg qd Oracea 40 mg 30 mg of doxy + 10 mg of extended release doxy $175 for 30 days (vs. $15) Periostat 20 mg BID $112

44 Alodox 20 mg Doxy (BID) Cleanser and scrub kid $$

$fracture Think sinusitis!$

45 Considerations in orbital blow out fracture Think sinusitis! Azythromycin Augmentum Ceftin Keflex

46 S/P Taekwondo

48 Oral Antibiotic Summary Preseptal cellulitis Ocular rosacea Dacryocystitis Chamlydia Coverage in a blow-out fracture

49 Oral Antivirals Significant role in preventing or minimizing complications Hasten resolution Reduces viral shedding & formation of new skin lesions Decreases both the incidence and severity of ocular complications

50 The many faces of herpes Herpes simplex virus Herpes zoster Bell s palsy

51 Antivirals Acyclovir: 200mg cap, 400 mg and 800mg tabs Valtrex: 500 or 1,000 mg tabs Famvir: 125, 250 & 500 mg tabs All pregnancy Category B All generically available

52 Herpes Simplex Signs and Symptoms Lip, nose (especially nares) and lid lesions Lesions are localized, vesicular, with intense pain and erythematous base. Vesicles rupture to ragged shallow ulcers

53 Herpes simplex virus Acyclovir 400 mg 5 x day x 7 days Valtrex 500 mg TID x 7 days Famvir 250 mg TID x 7 days Culture positive herpetic lesion

54 Zoster Pain prior to the onset of the rash is very common and often misdiagnosed

55 Zoster Acyclovir 800 mg 5 x day x 7 days Valtrex 1000 mg TID Famvir 500 mg TID Best: within 72 Hours

57 Treatment of Herpetic Disease Valtrex (Valacyclovir) Prodrug of acyclovir Zoster: 1 gram TID x 7 days Simplex: 500 mg TID x 7 days 1000 mg caplets are cheaper

58 Treatment of Herpetic Disease Famvir Zoster: 500 mg TID x 7 days Simplex: 250 mg TID x 7 days no therapeutic benefit over Valtrex and Acyclovir, same side effects Generic

59 Antiviral Side Effects Well tolerated GI disturbances Nausea Vomiting Abdominal pain Headache Dizziness Precaution in renal impairment Adjust dosage

60 Alternative dosages Herpes labialis new recommendation Valtrex: 2g q 12 hr x 1 day

NEI HERPETIC EYE DISEASE STUDY ACYCLOVIR PREVENTION TRIAL Recurrence rate of any form of ocular herpes was significantly lower in the acyclovir group (19%) than placebo

64 NEI HERPETIC EYE DISEASE STUDY ACYCLOVIR PREVENTION TRIAL Recurrence rate of any form of ocular herpes was significantly lower in the acyclovir group (19%) than placebo group (32%) Represents a reduction by 41% Rate of recurrence of stromal keratitis from 28% to 14% - 50% reduction Oral acyclovir 400 mg b i d x 1 yr Valtrex 500 mg once daily

65 To summarize: Rx: Valtrex 500 mg TID Disp # 21 Sig: 1 tab PO TID x 7 days

66 Concomitant conjunctivitis: consider the addition of Zirgan gel 5 x day

68 Take time to educate.

Ann Otol Rhinol Laryngol 1996 May;105(5):371-8 Murakami S, Mutsuhiko M et al: Bell Palsy and Herpes Simplex Virus.

69 Adour KK, Bell DN, Hilsinger Jr RL: Herpes simplex virus in idiopathic facial paralysis (Bell Palsy). JAMA 1975;233(6): Adour KK, Ruboyianes JM et al: Bell s palsy treatment with acyclovir and prednisone compared with prednisone alone: a double-blind, randomized, controlled trial. Ann Otol Rhinol Laryngol 1996 May;105(5):371-8 Murakami S, Mutsuhiko M et al: Bell Palsy and Herpes Simplex Virus. Annals of Internal Medicine 1996 January;124(1):27-39 Hadar T, Tovi F, Sidi J, et al: Specific IgG and IgA antibodies to herpes simplex virus and varicella zoster virus in acute peripheral facial palsy patients. J Med Virol. 1983;12(4): Kaygusuz et al: The role of viruses in idiopathic peripheral facial palsy and cellular immune response. American Journal o Otolaryngology 2004 November- December;25(6): Hato N, Matsumotos S et al: Efficacy of early treatment of Bell s palsy with oral acyclovir and prednisone. Otol Neurotol 2003 November;24(6): Takahashi H, Hato N, Honda N, Kisaki H, Wakisaka H, Matsumoto S, Gyo K: Effects of acyclovir on facial nerve paralysis induced by herpes simplex virus type 1 in mice. Auris Nasus Larynx 2003 February;30(1):1-5 Axelsson S, Lindberg S, Stjerniquist-Desatnik A: Outcomes of treatment with valacyclovir and prednisone in patients with Bell s palsy. Ann Otol Rhinol Laryngol 2003 March;112(3): Lagalla G, Logullo F, Di Bella P, Provinciali L, Ceravolo MG: Influence of early high-dose steroid treatment on Bell s palsy evolution. Neurol Sci 2002 Sept;23(3): Frankel D: Bell s palsy is due to herpes simplex virus 1. The Lancet 1996;347:108

70 Bell s Palsy and HSV Effects of acyclovir on facial nerve paralysis induced by herpes simplex virus type 1 in mice Auris Nasus larynx Feb;30(1):1-5 Clinical manifestations and treatment considerations of herpes simplex virus infection Journal of Infectious Disease 2002 Oct 15;186 Suppl 1:s71-7 Secretion and dynamics of herpes simplex virus in tears and saliva of patients with Bell s palsy. Otol Neurotol Sep;23(5): Pathophysiology of facial nerve paralysis induced by herpes simplex virus type 1 infection Ann Otol Rhinol Laryngol Jul;111(7 Pt 1): Mouse model of Bell s palsy induced by reactivation of herpes simplex virus type 1 J Neuropathol Exp Neurol Jun;60(6):621-7 Herpes simplex virus as a cause of Bell s palsy. Rev Med Viro Sapt-Oct;10(5): Bell s palsy and herpes viruses: to (acyclovir or not to (acyclovir?) J Neurol Sci Nov 15; 170 (1):19-23 Delayed facial palsy following uneventful middle ear surgery: a herpes simplex virus type 1 reactivation? Ann Otol Rhinol Laryngol Nov;107 (11 pt 1):901-5 Bell s palsy associated with herpes simplex gingivostomitis. A case report Oral Surg Oral Med Oral Pathol Oral Radiol Endod Sep;86(3):293-6 Bell palsy in association with herpes simplex virus infection. Arch Intern Med Jul 27;158 (14):1577-8

71 Bell s palsy treatment with acyclovir and prednisone compared with prednisone alone: a double-blind, randomized, controlled trial Ann Otol Rhinol Laryngol May;105 (5):371-8 Adour KK, Ruboyianes JM, Von Doersten PG, byl FM, Trent CS, Quesenberry CP Jr, Higchcock T. Conclusion.. We conclude that acyclovir-prednisone is superior to prednisone alone in treating Bell s palsy patients and suggest that herpes simplex is the probable cause of Bell s palsy.

72 Murakami Bell s Palsy and Herpes Simples Virus: Identification of Viral DNA in Endoneurial Fluid and Muscle Results: Herpes simplex virus type 1 genomes were detected in 11 of 14 patients (79%) with Bell Palsy

73 Bell s palsy and herpes simplex virus APMIS 1997 Nov;105(11): This well-controlled study provides conclusive evidence that reactivation of HSV genomes from the geniculate ganglia is the most important cause of Bell s palsy. Consequently, it has been suggested that Bell s palsy be renamed as herpetic facial paralysis.

74 Treatment of Bell s Palsy related to HSV If started within 72 hours Acyclovir 400 mg 5 x day x 7 days Sanford: Acyclovir 400 mg 5 x day x 10 days Prednisone: 60 x 4 days, 40 x 4 days, 20 x 4 days other: mg BID tapered and stopped at 10 days Prednisone mg x 1 week with no taper

75 What a Pain in the E%E!

76 Ocular Associated Pain Common Source: Corneal (Trigeminal, CN V) Uveitic (anterior chamber) pain CL related pain Post surgical pain Trauma related pain Periorbital pain Sinus Blunt trauma

77 Oral Pain Management Options Non-narcotics Analgesics NSAID Cox-2 inhibitor Non-narcotic centrally acting agents Narcotics Schedule II-IV More less addictive

78 OTC options for mild to moderate pain ASA: Salicylates* Not really a good choice 650 to 975 mg every 4 hours Contraindicated in ASA allergy, bleeding ulcers, bleeding disorders, people who drink more that 3 alcoholic beverages a day, pregnancy (category D), under 18 yo with viral infection Acetaminophen (ie. Tylenol): analgesic mg every 4 hours, max 3000 mg Contraindicated in liver disease, alcoholism and acetaminophen hypersensitivity Ibuprofen: NSAID (ie. Motrin) 200 to 800 mg every 4 hours, max 2400 mg Side effects stomach upset, GI toxicity (better if max dose is 1600 mg) Naproxen: NSAID(ie. Aleve) 200 mg every 8 to 12 hours, max 1500 mg Can use 2 tabs as a loading dose, with no more that 3 tabs in 24 hour period.

79 Oral NSAIDS Contraindicated in ASA allergies Precaution used in active peptic ulcer or GI disease, renal or liver impairment, heart failure, edema, HTN Adverse reactions: GI ulcer/bleeding/upset, headache, dizziness, fluid retention, rash, pruritis, tinnitus Prescription options: Cataflam (Diclofenac) 50 mg TID Initially can give 100 mg then follow with 50 mg TID Naproxen (Naprosyn) 500 mg BID

80 Cox 2 Inhibitors Better GI tolerance Celebrex Acute pain 400 mg initial dose, then 200 mg day 1 followed by 200 mg BID

81 Ultracet Opioid + acetaminophen Non-narcotic, centrally acting agent 37.5 mg Tramadol, 325 mg of acetaminophen Indications: Short-term (5 days) management of acute pain ii tabs q 4-6 hrs Ultram: Tramadol 50 mg

Interactions: Alcohol, CNS depressants, MAOIs, tricyclic antidepressants, anticholinergics Contraindications: Acute intoxication, hypnotics, narcotics,

82 Interactions: Alcohol, CNS depressants, MAOIs, tricyclic antidepressants, anticholinergics Contraindications: Acute intoxication, hypnotics, narcotics, centrally-acting agents, other opioids /psychotropics Adverse reactions: Dizziness, CNS depression, respiratory depression, GI upset, constipation, urinary retention

83 Narcotics (+analgesic) Examples Tylenol III Codeine phosphate 30mg, acetaminophen 300 mg Percocet 2.5/325 or 5/325 or 7.5/500 etc. Oxycodone and acetaminophen Lortab 2.5/500 or 5/500 etc. 2.5 hydrocodone bitartrate, 500 acetaminophen Vicodin Hydrocodone bitartrate and acetaminophen Adverse reactions: Dizziness, CNS and respiratory depression, GI upset, constipation, hepatotoxicity etc.

84 Lortab Opiod + analgesic Lortab 2.5/500 Hydrocodone bitartrate 2.5 mg + acetaminophen 500 mg Indications: moderate to moderatesevere pain Other dosages: 5/500; 7.5/500;10/500 Sig: 1 or 2 tabs q 4-6 hrs as needed for pain

85 Tips Check boxes: state law in Indiana Consider write out # given Never more that 5 refills Not valid after 6 months

86 The new face of drug addiction

87 Prednisone

88 Prednisone Contact dermatitis Temporal arteritis Orbital inflammatory pseudotumor Bell s palsy DLK Graves disease Optic neuritis Stubborn uveitis

89 Oral steroid use Precautions in patients with peptic ulcer disease, diabetes, TB, active infection, psychosis, or pregnancy. Side effects: Hyperglycemia, hypokalemia, hypertension, peptic ulcer, Incr. IOP, cataract, PTC, mental status changes, osteoporosis, decreased wound healing, fluid retention, other Proton Pump Inhibitor Prilosec: OTC Nexium Prevacid

90 Oral steroids Dosage varies widely For allergic responses, pulse therapy works well (60 mg x 3-4 days) Available in 1, 2.5, 5, 10, 20, 50 Taper NOT needed if used for 5-7 days or less Medrol dosepak Day 1

91 Prednisone Contact dermatitis 60 mg x 3 days with 20 day taper every 3 days. 60 mg x 1 week

92 Exacerbation of ezema Prednisone 40 mg x 5 days

93 Diamox Indications Adjunctive glaucoma Pseudotumor cerebri Acute angle closure Diamox 500 mg Diamox Sequels 500 mg

94 Diamox Contraindications Hypokalemia (low potassium) Hyponatremia (low sodium) Severe kidney, liver or adrenocortical impairment Hyperchloremic acidosis Cirrhosis Sulfonamide allergy

95 Diamox: Adverse reactions Anorexia Drowsiness, confusion Malaise Depression GI disturbance Paresthesias Tinnitus Initial hypokalemia Hyperuricemia Renal calculi Nephrotoxicity Hepatic dysfunction Blood dyscrasias Acidosis

97 CC: Headache

100 MRI: Small Chiari I malformation LP: elevated opening pressure (450mmH20) Slightly elevated BMI ( lbs)

101 Begin treatment Diamox Sequels: 500 mg BID testosterone by 50%

102

103 OTC Guidance

104

105 Allegra Antihistamine Fexofenadine Allegra 60 mg BID, 180 mg qd Allegra-D 60 mg BID reformulation of seldane does not to have the adverse affects with antifungals and macrolide nondrowsey moderate cost well tolerated

106 Systemic Allergies Symptoms Sneezing Itchy ears, throat, soft palate Popping ears secondary to fluid do to swelling of the eustachian tube swelling indicative of congestion Runny nose

107 Systemic Allergies Signs Nasal mucosa pale, boggy (edematous), bluish in color. Variants of nasal mucosa color: yellowish, gray, slightly erythematous SWELLING- may be very striking Lymphoid hypertrophy secondary to PND Allergic salute Profuse CLEAR discharge

108

109 Allergic shiners

110 Zyrtec 10 mg QHS once a day? drowsy affect taken at night Perennial allergies Precaution in hepatic/renal dysfunction other adverse reactions include dizziness, dry mouth Category B in pregnancy

111 Loratadine Claritin, Alavert, etc. nondrowsey easy dose break through of symptoms? Adverse reactions: HA, dry mouth, nervousness Claritin-D12 5 mg BID

112 Claritin-D24 10 mg QD Large pill, difficult to swallow Claritin Reditabs under the tongue for people who cannot swallow pills Nondrowsey

113 Oral Antihistamine Possible treatment for ocular myokymia In conjunction with topical steroids for severe contact dermatitis

Guiamax-D Mucinex D (+Maximum Strength) Expectorant and decongestant Generically available as Guaifenex GP: $15 x 10 days For consideration in relieving congestion associated with viral URI and

114 Guiamax-D Mucinex D (+Maximum Strength) Expectorant and decongestant Generically available as Guaifenex GP: $15 x 10 days For consideration in relieving congestion associated with viral URI and conjunctivitis Ocular pain associated with sinusitis Decongestant: 120 mg Pseudoephedrine Expectorant: 1200 mg Guaifenesin Maximum strength 240/2400 Prescription strength Guiamax-D BID x 10 days, disp #20

115 Contraindications: severe HTN, coronary artery disease, within 14 days of MAOIs Precautions: HTN (meds will be antagonized), DM, cardiovascular disease, NA glaucoma, elderly, prostatic hypertrophy, hyperthyroid

116 Adverse reactions: nervousness, insomnia, HA, GI upset, urinary retention Dry eye exacerbation

Grogg s Top 10 1. Dicloxacillin 2. Keflex 3. Azithromycin 4. Doxycycline 5.

117 Grogg s Top Dicloxacillin 2. Keflex 3. Azithromycin 4. Doxycycline 5. Allegra (-D) 6. Acyclovir/Valtrex 7. Lortab (Ultracet) 8. Prednisone 9. Guiamax-D 10. Diamox

118 Summary Preseptal cellulitis Dicloxacillin, Keflex, Azithromycin Ocular rosacea Doxycycline Allergies Allegra (D) Herpetic lesions Acyclovir/Valtrex

119 Summary Blow-out fractures Keflex, Z-pac Pain Lortab, Ultracet Chlamydia Azithromycin Orbital pain assoc. with sinusitis Guiamax-D and Z-pac PTC Diamox Sequels

120 Clinical References Monthly Prescribing Reference $79 year Epocrates Make friends with a pharmacist

121 Case examples

122 20 yo black female Painful, tender lower lid No vesicles PCN allergy: throat closes up What would you Rx?

123 What would you Rx? Ø Dicloxicillin Ø Keflex Ø Augmentum Azithromycin: Tri pak take as directed

124 24 year old patient with chronic seasonal allergies. Currently using Claritin OTC but it s just not doing the trick Also Pataday

125 What are your options? Zyrtec Allegra 180 mg qd

126 1 month check Better, but increased stuffiness and sneezing at bedtime What can you tweak? Allegra 60 mg BID

127 CC: Red eye (!)

128 Can you help me with this?

129 CC: Red eye Mouth sores 4+ cell 47 mmhg IOP

130 Recurrent lid edema

131 20D Myope, no back up glasses

132

133 Was seen upstairs

134

135

136 Thank You And try to get along....

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