Ocular Medication and Compliance Consultant for Alcon Disclosures CECELIA KOETTING, OD FAAO VIRGINIA EYE CONSULTANTS VOA CONFERENCE NORFOLK 2018 Virginia Optometry License Generic vs Brand Name Every state is different TPA certification What can be prescribed? All Ophthalmic topical drops classes Antibiotics, glaucoma, anti-viral, dry eye disease medications, allergy medication, NSAIDS, steroids, anti-fungal, cycloplegics Some oral medication classes NSAIDS, steroids, anti-viral, antibiotics, anti-fungal, allergy medications, glaucoma Pain relief medicaiton: Tylenol 3, and schedule III-VI Epinepherine(epi pen) Efficacy Dosage Preservatives Corneal toxicity Cost and insurance coverage Compounded Drops Preservative Free Dexamethasone Compounded Glaucoma medications Latanoprostand Brimonidine Tim-Brim-Latan Tim-Brim-Dorz-Latan Post operative drops Gati-Keto-Pred Keto-Pred Gati-Pred Compliance 1
How to Ask Ask the patients what medications they are taking If they can t name them, what color is the top Don t lead the patient, have them tell you the information Sometimes patients will just answer yes Bring their medications to the appointment Always ask how often they are taking it and when they took the last dose Don t forget to ask if they need refills! Compliance Studies You can do it! Okekeet al 2009 196 subjects given a TravatanDosing aid, an electronic monitoring device, to administer travoprost QHS Data over 8 week period on how often used Approximately 45% of patients who knew they were monitored and given free medication used their drops less than 75% of the time Patients report their use as higher than was actually measured Encouragement throughout the practice Timely refills Samples when needed Physician should consider cost to patient when can Entrance questioning Frequently Prescribed Ocular and Systemic Medications Antibiotics Topical antibiotics Fluoroquinolones Vigamox(moxifloxacin), Besivance, Ofloxacin, Ciprofloxacin, Gatifloxacin Aminoglycosides Tobramycin, gentamicin Macrolides Erythromycin, Azithromycin Other Bacitracin ointment, Polytrimetc 2
Uses of Topical Antibiotic Post Surgical Antibiotics Oral Antibiotics Augmentin Cecelor Azithromycin Doxycycoine Keflex Bactrim (Septra DS) Zmax Z-Pak Uses of Oral Antibiotics Allergy Medications Blepharitis Ocular Rosacea Hordeolum Preseptal Cellulitis Orbital Cellulitis Corneal Ulcer Antihistamines Blocks histamine and leukotriene release preventing chemotaxis of eosinophils Require a week or 2 for effect Mast Cell Stabilizer Stabilizes mast cell membrane Steroids Helps decrease inflammation of bulbar and palpebral tissues 3
Topical Allergy Medication Systemic Allergy Medication Mast Cell Stabilizer Alocril, Almode, Crolom Combination Alaway Pataday, Patanol, Pazeo Zaditor Lastacaft Bepreve Steroid Alrex Lotemax OTC Zyrtec Claritin Allegra Rx Singulair Glaucoma Medications Classes of Glaucoma Medications Method of Action Decrease aqueous production Increase uveoscleraloutflow Increase outflow Carbonic Anhydrase inhibitor Prostaglandin Alpha-2 Agonist Beta Blocker New drugs Carbonic Anhydrase Inhibitor Systemic CAI Azopt(brinzolamide 1%) Trusopt(dorzolamide 2%) Diamox (acetazolamide) Neptazane(methazolamide) Inhibition of carbonic anhydrase II in ciliaryprocess, slows formation of bicaronateand reduction of sodium and fluid transport Decreased production Patients with sulfa allergies should avoid 4
Prostaglandin Alpha-2 Agonist Travatan(travoprost) Vyzulta(latanoprostene bunod) Xalatan(latanoprost) Zioptan(tafluprost) Lumigan(bimatoprost) Increased uveoscleral aqueous outflow Works better at night (while sleeping when increased IOP) Don t use in patients with active inflammation or history of chronic inflammation Alphagan-P (brimonidine) Iopidine(apraclonidine) Reduces aqueous production and increases uveoscleral outflow Patients on MAOI is a contraindication in 0.2% concentration Beta Blocker Betagan(levobunolol HCL) Betoptic-S (betaxolol) Ocupress(cateolol) Timoptic and Timoptic XE (timolol maleate) Namenda Systemic Medication for dementia associated with Alzheimer's Thought to have neuro-protective properties Decreases production of aqueous humor Contraindicated in patients with Asthma, COPD, bradycardia, congestive heart failure New and Other Combinations Rhopressa(netarsudil dimesylate) Rho Kinase inhibitor Enhances trabecular outflow and decreases aqueous production Dosed QHS When used in conjunction with latanoprosthas shown to increase reduction of IOP of 30% in 65% of patients Combigan Cosopt Simbrinza Pilocarpine Cholinergic agonist 5
Steroids Steroids What are they used for Decrease inflammation uveitis, Post surgical Dry eye disease Corneal swelling Corneal transplant rejection rate Slow healing rate Deceraese corneal scarring Ucler, PRK Alrex Usually for ocular allergies Durezol(difluprednate) Fluoromethalone alcohol (FML) and FML Forte Lotemax gel, suspension and ointment(loteprednol etabonate) Maxidex(dexamethasone) Pred Forte (prednisolone acetate) Steroid Responders Oral Steroids Approx15% of people Causes an increase in ocular pressure Treat with IOP lowering topical medicaiton Usually occurs 3-4 weeks after starting steroid Can occur sooner with high doses of potent steroid Small subset of patients are super responders Used for persistantinflammation Used in patients for Optic neurtitisand NAION Prednisone NSAID NSAID What are they used for Episcleritis Scleritis Post surgical CME Uveitis/Iritis Less often place of steroids in steroid responding patients Helps to decrease inflammation as well as decrease ocular pain Topical Ketorolac/Acular Bromday and BromSite(bromfenac) Ilevro(nepafenac suspension) Prolensa(bromfenac) Voltaren(diclofenac sodium) Systemic Ibuprofen Naproxen sodium 6
Anti-Viral Anti-Viral When: Herpes Simplex and Zoster/Shingles Viral Conjunctivitis Ocular Viroptic(trifluridine) Zirgan (gangciclovir) Systemic Valtrex (valcyclovir) Famvir(famciclovir) Zovirax (acyclovir) Antifungal Anti-Fungal When: Fungal ulcers Ocular Natacyn Systemic Fluconazole Corneal Health Other Ocular Surface Disease Restasisand Xiidra Muro128 ABMD Recurrent corneal errosions Corneal edema Fuchs Mucomyst compounded Filamentary keratitis Lacrisert Tear film stabilizer Latisse Eye lash growth enhancer 7
Questions? Thank you! References Okeke, Constance O., et al. "Adherence with topical glaucoma medication monitored electronically: the TravatanDosing Aid study."ophthalmology116.2 (2009): 191-199. 8