High on Drugs. Erythromycin Only in ointment

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1 High on Drugs Joseph Shetler, O.D. 112 North Main Gordon, NE shetlerg@gpcom.net Part I : Drugs commonly used in optometric practices Antibiotics Fluorquinolones Highly effective Relatively expensive Central ulcerative keratitis Treat moderate to severe conjunctival and corneal infections Ultimate in antibiotics Treat aggressively Every ½ hour to every 15 mins in severe cases Conjunctival infections q2h-qid One drop per instillation Fluorquinolones Ciloxan: ciprofloxacin 0.3% Alcon Vigamox: moxifloxacin 0.5% Alcon Moxeza: moxifloxacin 0.5% Alcon Ocuflox: ofloxacin 0.3% Allergan Zymar: gatifloxacin 0.3% Allergan Zymaxid: gatifloxin 0.5% Allergan Besivance: besifloxacin 0.6% B & &L Quixin: levofloxacin 0.5% Vistakon Iquix: levoflaxcin 1.5% Vistakon Fluoroquinolones Inhibiting bacterial DNA Gyrase, an enzyme necessary for bacterial replication. Highly bactericidal even in low concentrations New to the line-up Aminoglycosides Less expensive Have generics Inhibit protein synthesis Most effective against gram negative, Pseudomonas, also effective against gram positive. Gram positive are becoming increasingly resistant Toxicity Epithelial breakdown, injection inferiorly Edema of eyelid tissue Not generally serious Availability Gentamicin: Sol and ointment Tobramycin: Tobrex Sol and ointment Neomycin: Not available in stand alone medication Erythromycin Only in ointment 1

2 Gentle Good antibiotic prophylaxis Inhibiting protein synthesis Staphylococcal resistance may develop Illotycin Inexpensive Drug of choice for bacterial blepharitis Breaks down cell walls Minimal toxicity Only in ointment form Polymyxin B Combinations Polymyxin B: potent killer of gram negative Destroys the cell s membrane structural and functional integrity Resistance, toxicity, and allergic rxs rare Allergan Trimethoprim, Interfers with folic acid synthesis In combination with Polymixin B Minimally toxic to eye Effective against Haemophilus Influenzae, and Streptococcus Pneumonia Childhood problems, peditricians #1 Rx Treat a full week, q3h Broad Spectrum (Polysporin) Bacitracin & Polymyxin B Good activity against most common pathogens non-toxin to epithelial tissue Hint Adults do not like ointment for daytime therapy. Bacitracin, Polymyxin B, Neomycin Solution and ointment Kills a broad spectrum 5% react hypersensitivity Erythema, mild edema SPK Resolves within a few days Cold compresses or mild steroids I avoid drug for this reason Azasite Azithromycin Inspire Pharmaceuticals Relatively expensive Long half life Dosage one drop q8 hours- q12 hours Inhibits Protein Synthesis Used significantly for pediatrics Glaucoma Medications Beta Blockers Prostaglandin Analogs Docosanoid Compounds 2

3 Alpha Agonist Carbonic Anhydrase Inhibitors Topical Beta Blockers Major workhorses, 25 year track record Most cost effective therapy Inhibit aqueous formation by blocking beta receptors on nonpigmented ciliary epithelium Concerns and side effects 10% of patients do not respond Bronchospasm, contraindicated in patients with asthma Avoid patients with significant Hrt disease The Timolols Timoptic Timoptic XE Betimol Timoptic First Beta Blocker 1978 XE Gel Based Delivery System Available Generically Betimol Not generically substitutable Available in.25% and 0.5% Good studies have shown QD effective as BID Betoptic S Safest Beta Blocker, more selective Blocks Beta 1 receptors only ( Beta 1 are primarily in cardio tissue, Beta 2 are primarily pulmonary Q12h Patients with hx of cardiac problems should avoid Patients with active COPD, emphysema, asthma should use alternative Prostoglandin Analogs Xalatan: Latanoprost Travatan: Travoprost Lumigan: Bimatoprost Systemically safest Enhancement of uveoslceral outflow Loosens the intercellular spaces within ciliary body Side effects Iris darkening Largely cosmetic Irreversible pigment changes 6-12months 5% develop uveitis 2% macular edema Hypertrichosis Darkening, lengthening, and thickening of eyelashes Avoid Prostaglandins History of uveitis, of CME Aphakia Yag posterior capsulotomy Hx of Herpes Simplex Keratitis Xalatan Pfizer 3

4 Significant medical milestone First prostaglandin for first line therapy Squeeze thin-walled bottle gently to avoid spillage Expensive $50-$60 per bottle Just went Generic Spring of 2011 Two weeks to achieve therapeutic affect Best tolerated of prostaglandins Travatan Z: Travoprost BAK Free, decrease in redness Travatan no longer available Alcon Similar to Xalatan Bottles are half filled to facilitate drop per ability Lumigan: Bimatoprost 30% reduction, similar to Travatan Z and Xalatan QD Dosage Greatest tendency to conjunctival hyperemia Opaque bottle Docosanoid Compounds FDA approved in Aug 2000 In use in Japan in 1994 Exact mechanism unknown, thought to enhance trabecular outflow Alpha Agonist Alphagan-P: Brimonidine (Generic) Alphagan-P Nontoxic preservative compared to BAK in Alphagan Primarily inhibit aqueous production Tid Reduces IOP 20-25% Dry mouth and fatigue Headache Alphagan P 0.1% Generic 0.15% and 0.2% Carbonic Anhydrase Inhibitors Reduce the carbonic anhydrase activity in the ciliary processes. Production of Aqueous humor is fx of bicarbonate Avoid in patients with guttata, endothelial compromise, significant ocular surface disease Trusopt: Dorzolamide Useful in asthmatics bid or tid dosage Bitter taste in throat Generic Azopt: Brinzolamide Alcon Performs similar to Trusopt Less stinging Minimal Shaking is required Cosopt 4

5 First glaucoma combination Dorzoamide and Timolol Maleate 30% reduction Bid Generic Oct 2008 Combigan Newest Combined Glaucoma agent Timolol Brimoonidine (Alphagan P) Expensive combination of relatively inexpensive drugs tid dosing Diamox: Acetazolamide Oral Carbonic Anhydrase Inhibitor Not rxable by ODs in NE Clinically effective Common side effects. Paresthesias, digestive problems Contra in renal or pulmonary problems. Allergy Drugs 40 million units of OTC 4 million rxs Acute Care Drugs Acular LS: ketorolac tromethamine, Allergan LS lower dosage 0.4 as opposed to Acular 0.45 Non-steroidal anti-inflammatory Raises sensory threshold of nerve endings to abate itching Approved for inflammation following Cat Qid x 2 wks Available in unit dosage post operatively Alrex Loteprednol etabonate 0.2% First topical coticosteroid, FDA approved for allergies Rarely causes IOP increase or cats Address all signs and symptoms of allergies Particularly effective in cases with considerable conjunctival inflammation Shake prior to instillation Emadine Emedastine Difumarate 0.05% Topical antihistamine Approved for temporary relief of allergy symptoms qid Safe and effective Patanol Olopatadine hydrochloride: Alcon Topical antihistamine with mast cell stabilizer properties. Patanol, 0.1% bid, Pataday, 0.2% is the only antihistamine, mast cell stabilizer approved for once daily use by FDA Zaditor 5

6 Ketotifen fumarate 0.025% Side by side with Patanol Antihistamine/mast cell stabilizer bid dosing Cl wearers install a few minutes before contacts and a few minutes after removal OTC Optivar Azelastine hydrochloride 0.05% Anti-inflammatory activity reduce influx of inflammatory cell Antihistamine properties Mast cell stabilizer Lastacaft Alcaftadine 0.25% Allergan New 2011 Once daily dosing Affinity for a histamine receptor associated with early phase of allergic conjunctivitis Bepreve New Topical 2010 Bepotastine besilate 1.5% No evidence advantage over other histamine receptor blockers $100 compared to OTC at $15.00 OTC All ketorolac fumurate 0.025% Alaway B&L Claritin Eye Schering-Plough Refresh Allergan Zaditor Novarits Chronic Care Drugs Stabilize mast cell membranes No direct anti-histamine or anti-inflammatory properties, poorly suited for acute allergy. Well suited for multiple-wk therapy Inhibiting the degranulation of mast cells, preventing them from releasing histamine Safe and can be used for weeks or months Alocril Alomast qid dosing Alamast Alocril slight yellow color, bid dosing Must be used regularly during at risk season Can be used to treat GPC Used with disposable SCL Due to long term toxicity avoid with annual replacement contact lenses Oral Antihistamines Allergic conjunctivitis, allergic sinusitis, and allergic rhinitis OTC: Benadryl, Chlor-Trimeton For safety and effectiveness Claritin: OTC 10mg qd Clarinex : 5mg qd 6

7 Zyrtec : 5mg, 10mg qd Allegra: 60mg bid, 180mg qd Corticosteroids Myth: elevated IOP: unlikely to occur before 3-5 wks of use Safe and effective treating ocular inflammation Steroids Maximum Clinical Action Pred Forte Inflamase Forte Vexol Lotemax Durezol Pred Forte Prednisolone Acetate 1% Allergan Highly prescribed, clinically proven Greatest anti-inflammatory efficacy Penetrates cornea and AC Iritis, Chemical, Thermal Burns, Episcleritis Avoid in epithelial breakdown and Herpes Simplex Steroids retard epithelial healing Generic Vexol Rimexolone 1% Alcon Similar to Pred Forte Decreased tendency for increased IOP Unique suspension formula re-suspended by picking up the bottle and shaking it minimally Lotemax Loteprednol Etabonate 0.5% Baush & Lomb Treatment of post operative inflammation Site specific Good intra ocular penetration, get to targeted tissue, undergo inactivation Minimal effect of IOP 0.2% formulation is Alrex Also Lotemax ointment Durezol Primarily beneficial due to dosing Frequency. Every 2hours as effective as Pred Forte q1h Moderate Strength Steroids Fluorometholone based Less effective Decreased propensity to elevate IOPs Useful for treating mild to moderate inflammation FML (Allergan) Fluro-Op (Novartis Chronic inflammation Mild to moderate inflammation 7

8 Less likely to increase IOP Available in 0.1%, 0.25% suspension 0.1% ointment Only steroid ointment not in combination Flarex: Alcon Eflone: Novartis More potent than FML Features greater penetration Still does not raise IOPS significantly Hydrocortisone Not available in pure ophthalmic form 1% OTC Treat Blepharodermatits Labels say for external use and not for ophthalmic use Should be applied only to skin Ophthalmic steroids better choice Combination Drugs Steroid antibiotic combination Ocular inflammation associated with risk of infection Good method of providing steroid and antibiotic in one medication Tobradex Tobramycin combination (generic) Dexamethasone 0.1% Solution and ointment Alcon Moderate to Severe Conditions Tobradex ST Dexamthasone 0.05% Xanthum Gum thickening agent allows Lower concentration to be effective Prednisolone & Sodium Sulfate Mild to moderate effect from prednisolone Minimal antibiotic effect Blephamide: Allergan FML-S: Allergan Pred-G Prednisolone-Gentamicin Suspension and ointment form Allergan Stings on insertion Steroid-Neomycin combo Neomycin Allergies Advantage: Price and generic Prednisolone Acetate and Neomycin and polymyxin B Poly-Pred: Allergan, Maxitrol: Alcon NeoDecadron: Dexamethasone neomycin, Merck Zylet New addition by Bausch and Lomb Loteprednol Etabonate Tobramycin (AB) Excellent antibosis Safety of loteprednol NSAID Inflammatory control without steroidal concerns Useful for postoperative treatment ocular inflammation, seasonal allergies 8

9 Pain Management Treatment of cystoid macular edema Very little risk of elevated IOP Voltaren/Acular LS Qid, clinical equivalents Voltaren dicclofenac 0.1% Novartis Acular LS ketorlac 0.4% Acular 0.5% Acular was uncomfortable and stinging upon instillation Acuvail Preservative free unit dose BID one day prior to cat surgery and continued for two weeks immediately post-op Very expensive Two New NSAIDS Nevanc nepafenac 0.1% Alcon Tid Bromoday: Bromfenac First NSAID daily dosing Nsaids not generally rxed beyond a week Potential for Corneal melting Who you gonna call? Proparacaine, Ak-Taine, Alcaine, Ophthetic Works within a minute Effective minutes Burning on instillation Rose Bengal Stings on insertion Stains necrotic cells Identifies Epithelial Break down Use White Light Herpes Simplex Keratitis Antiviral Viroptic: trifluridine Monarch/ Generic Old drug Indiscriminate Potentially toxic More frequent dosing q2h Refrigerate until opened Thiomersal preserved /Solution New Zirgan/ gel Infected cell specific Minimally toxic Less frequent dosing No refrigeration BAK Preserved 9

10 Expensive Fluorescein Sodium Delineates epithelial absence Requires Cobalt filter Slight stinging on insertion Mydriatics and Cycloplegics Dilate the pupil Paralysis accommodation Most frequently used topical medication in practice Effect of medication depends on age, race, eye color Adrenergic Agents Pupil dilation Increase in outflow of aqueous humor Vasoconstriction Relaxation of ciliary muscle Stimulates the iris dilator muscle Adrenergic Agents Avoid Hypersensitivity Narrow angle glaucoma Phenylephrine 10%, Avoid diabetics, hypertensive, aneurysms, cardiac disease, infants and small children, Patients on HTN meds or antidepressant. Avoid 10% Stinging on instillation, photophobia Phenylephrine Hydrochoride Trade names AK-Dilate, Neo-Synephrine Mydfrin, Available generically Soln 2.5%, 10% Onset minutes Duration 3-5 hours Cycloplegic Mydriatics Anticholinergic Block responses of the sphincter muscle of the iris Blocks muscle in ciliary body to cholinergic stimulation Producing pupil dilation and paralysis of accommodation. AntiCholinergic agents Atropine Homatropine Scopolamine Cyclopentolate Tropicamide 10

11 Indications: cycloplegic refraction, dilation in inflammatory conditions Contraindications: glaucoma, narrow AC Hypersensitivity Use with caution: pregnancy, Do not use atropine or homatropine under 3 months Adverse Reactions Increased IOP stinging, hyperemia, photophobia Systemic: Flushing and dryness, rapid irregular pulse, mental aberration, respiratory depression, psychotic reactions Atropine Sulfate Atropisol, Atropine-care, Isopto Atropine, available generically Available in ointment Onset minutes Duration 7-14 days Potent Cyclopentolate Cyclogyl 0.5% Cyclopentolate, AK-Pentolate, Cyclogel, Pentolar 1% Cyclogel 2% Onset minutes Duration 6-24 hours Homatropine Moderately long-acting mydriatic and cyclopelgic for refraction and uveal tract inflammation Homatropine HBr, Isopto Homatropine, 2% Homatropine HBr, Isopto Homatropine, 5% Onset minutes, Duration 3 days Tropicamide Mydriacyl, AK-Tropicacyl: Generic, 0.5 1% Onset minutes Duration 4-6 hours Paremyd Combination 0.25% Tropicamide & 1% Paredrine, Hydroxyamphetamine HBr Hydroxyamphetamine enhances dilation of Tropicamide because dilator muscle is also stimulated, only ¼ to ½ Tropicamide % Onset minutes Duration 3-4 hours Availability is always a concern Fluorescein Sodium & Benoxinate Hydrochloride Contains epithelial dye Anesthetic Routinely for Tonometry Epithelial Evaluation Dry Eye Products Lissamine Green Evaluating dry eye Does Not Sting Stain pattern evaluated for mucin defiency Overview Unit dose vs multidose 11

12 Preservatives vs preservative free Viscosity Gel formulas preservative free and give longer relieve Low viscosity Corneal abrasions UV keratitis Herpes Simplex Herpes Zoster GPC Adenoviral Low viscosity PF or nontoxically preserved GenTeal Mild: multidose GenTeal Hypotears PF: Unit dose Moisture Eyes: Unit dose Refresh Plus: Unit dose Refresh Tears: Multi dose Tears Natural II: Unit dose and multi dose Tears Natural Forte: Multi dose Thera Tears: Unit dose and multi dose Unit Dose Optimal Refresh Plus Moisture Eyes Thera tears Non Toxically Preserved Multi dose GenTeal: Works as SCL and RGP wetting drop Refresh Tears: NA Chlorite which rapidly degrade to CL ions and H20 upon instillation Thera Tears Restore conjunctival goblet cell formation Improve electrolyte balance Micronutrients help restore corneal fx and integrity Unit dosing or 15ml bottle Tears Natural Forte Enhanced Tears Natural II by adding 0.2% glycerin Enhances lubrication Reduces corneal edema Premier Artificial Tears GenTeal Refresh Tears Thera Tears Tears Naturale Forte Soothe Soothe XP Soothe XP stable in dry eye treatment Restoryl (Active ingredient in Soothe XP doubled lipid layer thickness Supports mucin layer Supports Aqueous layer 12

13 Moderate Viscosity Artificial Tears Benefits patients with moderate to advanced tear film instability and epithelial compromise Bion Tears Preservative free Unit dose Bicarbonate Must be kept in foil which can be challenging for arthritic patients OcuCoat PF Preservative Free Bausch and Lomb Sustained Lubrication High Viscosity Artificial Tears Persistent keratitis of unknown etiology Keratitis secondary to a significant dry eye problem Can replace bedtime ointment in patients who need nocturnal lubrication Transient blurring AquaSite Refresh Celluvisc Unit dosage Refresh Liquigel Multi dose Murocel Gel Formulations Initial blur of 1 minute 2-5 hours of symptomatic relief Tube delivery system Highly viscous when coming out of tube May replace high viscosity and ointment Not for use with cls GenTeal Gel Tears Again Lubricating Ointments Uncommonly used Severe enough to warrant nighttime therapy Incomplete closure Severe epithelial compromise Systane New artificial tear Formulation interacts with compromised glycocalyx-mucin-microvillic (foundation of pre corneal tear Demulcent bioadhesive bandage Ph 7.0 interacts with surface 7.4 Gel like coating Prolonged lubrication 15 ml bottle. Refresh Endura Refresh Line of Products Endura is the vehicle of Restatsis Formulation is purported to contribute to all three tear film layers Prolonged lubrication 13

14 Preservative free unit dose Restasis Restasis Cyclosporin, Allergan Action Inflammation of the lacrimal gland and ocular surface tissue is targeted Available in 0.05% unit doses BID Inhibits activated T-Cells Not clinically significant for 3-4 month Full therapeutic affect for 6 months. Expensive: Available in 32 unit dosage for about $100, over $1000 per year May get two day therapy out of unit to cut costs Only 15% of candidates get therapeutic effect 17% of patients experience ocular burning Prescriptive, not OTC Oral Therapy for Dry Eye Nutritional Supplements Omega 3 fatty acid supplementation can be beneficial if meibomian gland dysfx Found naturally in fish oils and flaxseed Render an anti-inflammatory affect Thera Tears Nutrition gel capsule Hydrate Essential Liquid form NaCl for corneal edema Muro 128 solution 2% 5% Reduces corneal edema Ointment of nighttime therapy Vitamin and Mineral supplements Snake oil or beneficial Paul Harvey Says I use Eye Brite What is a Doctor and ParaOptometric to do? Age Related Eye Disease Study 3640 Patients Followed Mean 6.3 years Product used Bausch and Lomb Preser Vision Category 1 No AMD Less than 5 small drusen 20/32 or better vision Category 2 Early AMD mild or borderline Multiple small drusen Pigment abnormalities Category 3 Intermediate AMD 14

15 Absence of advanced AMD One eye better the 20/32 Category 4 Advanced AMD Visual Acuity 20/32 or better, no geographic atropy Fellow eye vision less than 20/32 AMD Advanced, abnormalities to account for reduced vision Results Group taking Preservision had a 25% reduction in rate of AMD progression. Only patients in Category 3 and 4 showed a statistical difference Patients were followed for 6.3 years What to do? Practice evidence based medicine on Category 3 and 4 Practice speculative, rational principles for other categories Recommended two tabs in AM, two more at night Principles to keep in mind Beta-carotene may enhance lung cancer rate in Smokers Vitamin A and Lutein compete for absorption sites, avoid high concurrent doses Vit A D E and K fat soluble and have potential to accumulate to toxic levels Supplementation had no effect on rate of cataract development Role of Lutein Leutin Not commercially prepared at time of study For years at risk patients advised to eat dark, leafy greens Competes with Beta Carotene OcuVite Lutein is recommended as a general health eye vitamin Preser Vision can be regarded as a disease specific vitamin supplement Some practioners are recommending rotation of the two supplements AREDS 2 Results anticipated in 2013 Macular nutrition counseling is part of PQRI System Medications You can t possibly know them all, ie don t feel bad you MD doesn t either Don t be afraid to ask what a medication is for Don t be afraid to ask how to spell a medication. Don t be afraid to check with the pharmacist Don t be afraid to ask for a medication list Try to learn one new drug a week Resources to consider PDR Hard copy Pocket PDR, recommended Clinical Pearls Review of Optometry Your Pharmacist 15

16 Chloroquine Derivatives Plaquenil Arthritis treatment 400mg per day standard dose Yearly exams in healthy patients, previously every 6 months Tamoxifen Another Cholorquine derivative To prevent recurrence of breast cancer and preventative in high risk Causes drusen like deposits in 6%, also cause keratopathy and optic neuritis VA loss is reversible if d/c before less than 20/70, retinal changes permanent MONITOR CAREFULLY Antihistamines Allergic disease, Seasonal allergies OTC various brands Zyrtec, *Allegra, Claritin, Clarinex Dryness of mucosal membranes Dilation of pupils and loss of accommodation in borderline presbyopes, Cardiovascular Drugs Diuretics Can cause transient blur due to fluid loss Diuril, *Lasix, Demadex Potassium Sparing diuretics, Diazide, Aldactone Cardiac Glycosides Digitalis, Digoxin (*Lanoxin) Used for congestive hrt failure, atrial flutter Easy to overdose First signs; Visual disturbance, hallucinations and color vision disturbance Antianginals, nitrates Combined with Viagra, heart stoppage Short Acting, Under tongue, Nitrostat Long Acting Imdur, Isordil Patches Nitrodisk, Nitro-Dur Can cause visual disturbance due to vasodilation effects Antiarrhythmics Calcium channel blockers Indications: arrhythmia, angina, hypertension, migraines Cardizem, Norvasc, Procardia, Verapamil Mechanism, vasodilation of coronary and peripheral vasculature Makes antiplatelet side effect of ASA worse Sever hypotension Beta adrenergic blockers Mechanism, blocks Beta 1 receptors in the heart and slows it Blocks Beta 2 receptors in lungs and eyes, constricts bronchioles and reduces aqueous production Dilates blood vessels Indications, angina, anxiety, HTN, migraine, arrhythmia Examples, * Atenolol, Betaxolol, Inderal, *Lopressor 16

17 Side effects, bradycardia, asthma exacerbation, fatigue depression, IOP reduction ACE (Angiotensin converting enzyme) inhibitors Mechanism, intercepts body s natural vasoconstriction mechanism to reduce blood pressure Indications, HTN, CHF Rarely blurred vision Examples, Lotensin, Capten, Vasotec, Altase, Prinivil Blood Thinners Indications, improve circulation, decrease clotting Examples, aspirin, Warfarin(Coumadin) Side effects, hemorrhage including ocular Cholesterol Lowering Agents Mechanism, inhibit cholesterol synthesis in the liver Indications, hyperlipidemia Examples, Mevacor, Zocar, Lipitor Side effects, rarely conjunctivitis, tearing and blurred vision Oral Hypoglycemics First Generation Stimulates insulin release from the pancreas Examples Diabinese, Tolinase, Orinase Second Generation Stimulates insulin release from the pancreas Examples, Glipizide (Glucotrol) Glyburide (Diabeta, Micronase, Glynase) Insulin sensitizers Examples, Glucophage, Avandia, Rezulin, Side effects, hypoglycemia, refractive changes Injectible Insulin Humulin N Dosage very individualized Stomach Proton-pump inhibitors, suppress gastric acid *Prevacid, Nexium, (the purple pill) Inhibits daytime and nocturnal gastric acid secretions as well as gastric acid stimulated by food, *Zantac Common drugs *Advair, maintenance treatment of asthma *Fosamax, for osteoporosis, acts as inhibitor of bone reabsorption to increase bone density *Premarin, Hormone replacement *Zoloft, Prozac, Paxil, Depression Oral Antibiotics Drug name-brand name Dicloxacillin- Dynapen Cephalexin- Keflex Amoxicillin- Augumentin Cefadroxil- Duricef Ciproflaxin- Cipro Azithromycin- Zithromax Doxycyline- Monodox Levoflaxcin- Levaquin Ofloxacin- Floxin Common AB useage 17

18 Keflex, antibiotic workhorse Works well against bacteria in and around ocular surface Augmentin, expensive Zithromax, chylamidal conjunctivitis single dosage of four 250 mg tablets Antivirals Valuable in managing Herpes Zoster Valuable in treating Herpes Simplex Safe for children with proper dosing Available in liquid form Analgesics OTC Non-Narcotic Narcotic OTC Acteminophen, Tylenol, analgesic, and anti-pyretic, the clear leader ASA, reduces pain, fever, inflammation, but risk of GI bleeding Ibuprofen, Motrin, Advil COX-2 inhibiting drugs Normal prostaglandins, maintenance of gastric mucosa, renal fx, coagulation Inducible prostaglandins response to inflammation. COX-2 inhibitors spare the maintenance mechanism and prevent inflammatory response Oral Nacotics Codeine, Tylenol #3 Mild to moderate pain Hydrocodone, Vicodin Moderate Oxycodone, Percodan Severe 18