8/9/18 - mimhtraining.com

8/9/18!

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OralMedicationsinOptometry

MarcR.Bloomenstein,OD,FAAOSchwartzLaserEyeCenter

Disclosure

•  PresenterisonspeakerspanelofAlcon,Allergan,J&J,Bausch+Lomb,Reichert,OcuSoft,SunPharm,TearLab

•  PresidentofMRBEyeConsultants•  Past-PresidentoftheOptometricCouncilonRefractiveTechnology(OCRT)

•  PresenterhasNOfinancialinterestinanyproductsmentioned

Precautions….•  Dotheyneedit?•  Haveyoudiscussedallergicresponse?•  Dotheyhavesystemicconditionsthatmayaffectthemedications?– Kidneyorliverfailure

•  Prescribingforthewomenandchildren..

Marc R. Bloomenstein, O.D., F.A.A.O License # 884 DEA #MB0628543

!8416 E. Shea Blvd. , Ste C-101, Scottsdale, AZ 85260 (480) 483-3937!

18275 N. 59th Avenue, Ste B108, Glendale, AZ 85308!!!!!

NAME AGE !!!

ADDRESS_____________________________________________________ DATE !!

Rx!!!

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REFILLS-- ! Dispense As Written Substitution Permissible!

ABBREVIATIONS•  ad-daily•  bid-twicedaily•  tid-threetimesdaily•  qid-fourtimesdaily•  qod-everyotherday•  5Xdaily•  9Xdaily

•  gtt-drop!•  ung-ointment!•  po-by mouth!•  IV-intravenous!•  IM-intramuscular!•  SQ-subcutaneous!

ABBREVIATIONS

•  wc-withfood•  tud-takeasdirected•  ud-asdirected•  ac-beforemeals•  pc-aftermeals•  qhs-everybedtime•  prn-asneededfor•  UAT-untilalltaken

•  achs-before meals and at bedtime!

•  sx-surgery!•  tx-treatment/therapy!•  NKDA-no known drug

allergies!•  N/V-nausea & vomiting!

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MEASUREMENTS

•  mg-milligram•  kg-kilogram•  1kg=2.2lb•  1cc=1ml•  1tsp=5ml•  1tbsp=15ml•  1ml=20drops ANTI-BIOTIC

ORALANTIBIOTICS•  Isanoralantibiotictrulyneeded?

•  Checkallergyinformation•  Uselessexpensiveantibioticswhenpossible•  ConsidercoveringforHaemophilusinfluenzaeinpediatricpatients–  LessHflusinceHibvaccinebecamewidespread

•  Takefullcourseoftherapy?–  ProfJodiLindsay,ProfessorofMicrobialPathogenesis,StGeorge’s,UniversityofLondon•  “Farfrombeingirresponsible,shorteningthedurationofacourseofantibioticsmightmakeantibioticresistancelesslikely.”

OCULARANTIBIOTICUSES

•  Preseptalcellulitis•  Dacryocystitis•  Dacryoadenitis•  Canaliculitis•  Chlamydia•  Dryeye/posteriorblepharitis/ocularrosacea•  Posteriortoxoplasmosisactivation•  Endophthalmitisprevention

ALLERGICREACTIONS

•  HypersensitivityreactionmediatedbyIgE– 5-10%ofalladversedrugreactions

•  Skinrash,hives,oritching•  Wheezingortroublebreathing•  Swellingoftheface,lips,orthroat•  Nausea,vomiting,diarrhea– Discontinueuseimmediately;Consultphysician– Severereactionsdemandemergencycare

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AMOXICILLIN

•  Penicillinantibiotic(aminopenicillin)•  ExtendedcoverageoverstandardPCN•  Goodforstaphinfectionsbecauseresistanttobetalactamases

•  Alsohassomegramnegativecoverage– Gramnegativeresistanceincreasing–  Inexpensive

ORALANTIBIOTICS

•  Controversialwhetherantibioticsandbirthcontroltrulyinteract-stillcounselanddocument

•  Cancausethrush,vaginalyeastinfections– Takedoseswithyogurt

•  Stopantibioticifpatientreportsseverediarrhea/bloodinstool– Concernsofpseudomembranouscolitis

AMOXICILLINDOSAGE•  Skinandsofttissueinfections•  Adults– 875mgq12h

•  Children– 20-40mg/kg/daydividedq8h

AUGMENTIN

•  Amoxicillin+Clavulanicacid•  Contraindicatedinpenicillinallergic•  Clavulanicacidisa“suicideinhibitor”– Protectsamoxicillinfrombeta-lactamases– Doesnothaveantibioticactionitself

•  Allowsincreasedcoveragewithlessdestructionbybeta-lactamases

•  Alsocoversanaerobes– Goodforhumanandanimalbites

AUGMENTININFO

•  CategoryB•  Canuseinchildren•  Cancausenausea/vomiting/diarrhea•  Takewithfood/yogurt•  Fewdruginteractions– Allopurinol/probenecid(bothforgout)

•  Adultrecommendeddosage:875mgbid•  Genericavailable




NAME Henry Bemis AGE !!!

ADDRESS_____________________________________________________ DATE 6/17/14 !!

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

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REFILLS--0 ! Dispense As Written Substitution Permissible!

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CEPHALOSPORINS•  Beta-lactamantibioticclass•  Increasedcoverageoverpenicillinclass•  3-10%cross-sensitivitytopenicillinclassinregardstoallergicreactions

•  Fourgenerationsofcephalosporins–  Increasinggramnegativeactivityfrom1to4

•  Firstandsecondgenerationsbetterforocularconditions(morelikelygrampositive)

CEPHALEXIN

•  BrandnameKEFLEX®•  Firstgenerationcephalosporin•  Goodgrampositivecoverage(Staph/Strep)•  Goodforchildren/Pregnantfemales•  Cheap•  Adultdoseis500mgbid•  Alsoavailableinsuspensionforchildren–  20-40mg/kg/daydividedq8h




NAME Jackie Payton AGE !!!

ADDRESS_____________________________________________________ DATE 6/12/14 ! Rx Keflex 500mg 1 po bid UAT #20

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!REFILLS—0 ! Dispense As Written Substitution Permissible!

ALLERGICTOPENICILLIN?

•  Smallpercentageofpatientswillalsobeallergictocephalosporins

•  Literaturesuggestsanywherefrom3-10%cross-sensitivity

•  Couldusea–mycin,–cycline,-quinolone•  CoulduseSeptraifnotsulfaallergic

MACROLIDES

•  Inhibitbacterialproteinsynthesis•  Erythromycin,clarithromycin,azithromycin•  Usewithcautioninliverdisease•  Druginteractionsincreased(nextslide)•  Greatforpenicillinallergicpatients

SELECTMACROLIDEDRUGINTERACTIONS

•  Theophylline(asthma,COPD)•  Dilantin,Tegretol,Depakote(epilepsy)•  Digoxin(Congestiveheartfailure)•  Coumadin(anticoagulant)•  Zocor,Mevacor,Lipitor(cholesterol)•  Norpace(antiarrythmic)•  Manyantiretroviral(HIV)medications•  Ergotderivatives(migraines)

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ZITHROMAX(Azithromycin)

•  Macrolideantibiotic•  Dosingregimenincreasescompliance•  OKinpregnancyandchildren•  LessGIeffectsthanerythromycin•  Lessdruginteractionsthanothermacrolides•  Drugofchoiceforchlamydialconjunctivitis

ZITHROMAX

•  Z-pack– 500mgdayone;250mgdays2-5– Greatforcompliance– Formilderinfections

•  Treatmentofchlamydiawith1gdose– Prescribefour250mgtablets– Takeallatonce

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NAME Brandon Flowers AGE !!!

ADDRESS_____________________________________________________ DATE 6/18/14 !!

Rx Z-pack!Use as directed!

!!!!


Whenthenormaltreatmentisnotworking!Chlamydia




NAME Steve Ferrucci AGE OLD !!!

ADDRESS_____________________________________________________ DATE 6/18/14 !!

Rx Zythromax 250 mg #4!Take all (4) pills at once!

!!!!

REFILLS—0 ! Dispense As Written Substitution Permissible!

-CYCLINES

•  Inhibitsbacterialproteinsynthesis•  Effectiveinblockingenzymes•  Tetracycline,Doxycyline,Minocycline•  Cannotuseinchildrenyoungerthan8•  Cannotuseinpregnancy/nursing•  Causesphotosensitivityandphotophobia•  Long-termtherapyassociatedwithpseudotumorcerebri(rare)– Minocyclinemorethanotherforms

DOXYCYCLINE•  Goodbroadspectrumactivity

•  Actsasaantibiotic•  Actsasaanti-inflammatory•  DONOTRx– childrenunder8– pregnantornursingfemales

RulesofThumbwithDoxy

•  DoNOTtakebeforelyingdown– wait2hours

•  DoNOTtakewithcalcium– avoidantacidsfor2hours

•  DoNOTtakewithdairyfoods•  Dotakewithfood

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OCULARUSES

•  Antibioticuse– 100mgbidx10days

•  MGDandDryeye– 1000mg1dose– 50mgbidx4-6weeksthen

– 50mgqdx3-6monthsorindefinitely




NAME William Clinton AGE !!!

ADDRESS_____________________________________________________ DATE 6/12/14 !!

Rx!Doxycycline Hyclate 100mg #60!

1 po bid with food!!

!!!

REFILLS—3 ! Dispense As Written Substitution Permissible!

LEVAQUIN

•  Afluoroquinolone•  CanbeusedforpatientsallergictoPCNand/orcephalosporin

•  OKforhordeolum/preseptalcellulitis•  HassomecoverageagainstMRSA•  500mgqdx7-10days•  Noinchildren/pregnancy/breastfeeding

ANTIBIOTICUSAGE

•  Usethefullcourseoftreatment??

•  Counselanddocumentdiscussionaboutbirthcontrol

•  Watchforthrushoryeastinfections–  usewithyogurt

•  Watchforintestinaldistress:–  diarrhea–  bloodinstool

DRYEYEUSES

DRYEYEORALAGENTS

•  Salagen®(oralpilocarpineHCl)– 5mgqidfordrymouth

•  Evoxac®– 30mgtidfordrymouth

•  OralmedsapprovedfordrymouthassociatedwithSjogren’spatientsandhead/neckradiation

•  CanconsiderforDES

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GLAUCOMA

DIAMOX(Acetazolamide)

•  Treatmentofacuteangleclosureglaucoma•  TreatmentoflessacuteincreasedIOP•  Treatmentofpost-surgicalIOPspikes•  Treatmentofpseudotumorcerebri•  Controversialtreatmentofserousretinaldetachments

•  Alsousedtoprevent“altitudesickness”


•  Nonbacteriostaticsulfonamide•  Decreasescarbonicanhydrase– Decreaseshydrogenandbicarbionformation

•  Resultsindecreasedaqueousproductionintheciliarybody

•  Resultsinalkalinediuresisinthekidneybuttolerancedevelopsquickly

•  Contraindicatedinrenal,hepatic,orrespiratorydisease


•  Decreasescarbonicanhydraseintheciliarybodywhichdecreasesaqueoushumorformation

•  DecreasesIOPby40-60%•  Startstoworkin1hour,peakeffectat4hours

•  Comesin125mg,250mg,500mgsequels•  Angleclosuredose:(2)250mgtabletsinitially—needsPI


•  Treatmentofpseudotumorcerebri•  NeedCBCwithdifferentialasbaseline•  Start500mgsequelsbid•  Oftenresultsintingling,“pinsandneedles”inextremities– Canlowerdoseto250mgbid– CantryNeptazane50mgtid

DIAMOXSIDEEFFECTS

•  Rarewithshorttermuse•  Paresthesias(“pinsandneedles”)•  Kidneystones•  Acuterespiratoryfailure•  Acid-baseimbalances•  Blooddyscrasias(aplasticanemia)•  Inducedmyopia•  Metallictaste

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SULFAALLERGY

•  Sulfaallergynotsulfurallergy•  Rashiscommonsign;usuallyseenintheantibioticclassofsulfonamides(likeSeptra®orsulfacetamideointment)

•  Lesslikelytoseeinnon-antibioticmeds•  Diamox®,Neptazane®,Azopt®,Trusopt®,Cosopt®

•  Evenlesslikelytoseewithtopicalmedications•  Sulfitesandsulfatesarechemicallydifferent-nocrossreactivitywithsulfaallergies

OSMOGLYN®

•  Glycerin50%oralsolution•  Anosmoticdiuretic•  DecreasesIOPquickly;butlastsonly1-2hrs•  1-2g/kgorallyforinitialdose•  Avoidindiabeticsduetohighcaloricload•  Riskofdehydrationinelderlyandthosewithkidneydisease

•  Causesnauseaandvomiting•  Worsenscongestiveheartfailure

PAINMEDS

PAINCONTROL

•  ScheduleII,IIIandIVanalgesics•  Non-scheduledpainmeds•  Cornealabrasions,post-opPRK,post-oppterygiumsurgery,etc.

•  Donotuseininfectiousprocesses,willmaskpainofworseninginfection

•  Shorttermtherapyonlyrecommended•  NeedDEA#toprescribescheduledmeds

CODEINE

•  Naturallyoccurringsubstance•  Fromtheopiumpoppy•  1/12thestrengthofmorphine•  Rarelyusedalone– Tylenol#3®(APAPandcodeine)– Empirin#3®(ASAandcodeine)

•  Alsousedasanantitussiveincoughsyrups

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CODEINECOMBINATIONS

•  Tylenol#3®andTylenol®#4•  Increasingcodeineamountfrom#3to#4•  APAPamountis325mgineach•  #3-30mgcodeine+325mgAPAP•  #4-60mgcodeine+325mgAPAP•  Tylenolwithcodeine®elixirisAPAP120mg/5ccwith12mgcodeine/5cc

TYLENOL#3

•  ScheduleII•  Centralactingnarcoticanalgesic•  325mgacetaminophen(APAP)+30mgcodeine

•  Avoidinliverdisease/alcoholism•  NoextraTylenol®inaddition•  Noalcohol•  GIdistressandsedationaremainsideeffects

ALLERGICTOCODEINE?

•  Mostinternistsstillusehydrocodonebecauseitisasyntheticformofcodeine

•  Mostcodeine“allergies”arejustGIsideeffects

•  TrueIgEmediatedallergicreactionlow

HYDROCODONECOMBINATIONS

•  EffectiveasClassIInarcotics•  Significantlymorepainreliefanddurationofactioncomparedtocodeine

•  Induceseuphoria•  Highlyaddictive•  Alsohasantitussiveproperties

HYDROCODONEPRODUCTS

•  Vicodin(APAPw/hydrocodone)– 300mgAPAP+5mghydrocodone– ScheduleII

•  VicodinES(APAPw/hydrocodone)– 300mgAPAP+7.5mghydrocodone– ScheduleII

•  Vicoprofen– 200mgibuprofen+7.5mghydrocodone– WhenTylenol®iscontraindicated/liverdisease– ScheduleII




NAME TylorDurden AGE !!

!ADDRESS______420PaperSt.Wilmington,_DE_____________________ DATE 10/22/87 !

! Rx Vicodin 5/300 #30 (thirty)

1-2 q4-6h prn pain !

!!!

REFILLS-- 0 ! Dispense As Written Substitution Permissible!

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SIDEEFFECTSOFPAINMEDS

•  Constipation•  Nauseaandvomiting•  Sedation•  Dizziness•  Itching•  Respiratorydepression•  Addiction

NSAIDS

•  KETOPROFEN– Ketoprofenisanonsteroidalanti-inflammatorydrug(NSAID).Ketoprofenworksbyreducinghormonesthatcauseinflammationandpaininthebody.Ketoprofenisusedtotreatpainorinflammationcausedbyarthritis.Theketoprofenregularcapsuleisalsousedtotreatmildtomoderatepain,ormenstrualpain.

– TAKEWITHFOODINSTOMACH

ORALANTIHISTAMINES

•  Centralactingantihistamines– Benadryl(diphenhydramine)

•  Peripherallyactingantihistamines– SelectiveperipheralhistamineH1receptorblockade– LessCNSandanticholinergiceffects– Lesssedatingbutalsolesseffective– Claritin,Allegra,Zyrtec– Allavailablewithandwithoutadecongestant– ZyrtecandClaritinavailableOTC

MYFIRSTCHOICE

•  ZYRTEC®•  Non-sedatingantihistamine•  Lessocularsurfacedamage– WhencomparedtoClaritin®

– Stillavoidindryeyeifpossible•  Lessdruginteractions•  Lessexpensive

ZYRTEC(Cetirizine)

•  Adultdosage:10mgqd•  Pediatric>5yo:5-10mgqd,2-5yo:2.5-5mgqd

•  Canbeuseddownto6monthsofage•  Comesin5mg,10mg,and1mg/mlsyrup•  w/oregardtofood•  Availablewithandwithoutadecongestant

ORALANTIVIRALS

•  InhibitviralDNApolymerasewithoutinhibitingnormalcellularactivity

•  Welltoleratedandsafe•  Decreasedosageinrenaldisease•  All3drugssimilarinefficacy--notinprice– Acyclovir7daycourse =$35.78– Famvir7daycourse =$237.88– Valtrex7daycourse =$243.36

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ORALANTIVIRALS

•  Foundintears•  Canuseforepithelialdiseaseifpatientcan’tuseViroptic®/Zirgan®secondarytotoxicity/severedryeye/availability

•  Doesnothelpinthetreatmentofstromaldisease

•  TreatstromaldiseasewithPredForte®1%•  CoversteroidwithViroptic®/Zirgan®ororalantiviral

ORALANTIVIRALS

•  Herpessimplexkeratitis•  Inplaceoftopicaltreatment– Acyclovir400mg5xdayx10days– Famvir®250mgtidx7days– Valtrex®500mgtidx7days

•  Forpreventionofrecurrences– Acyclovir400mgqd-bid– Famvir®250mgqd– Valtrex®500qd

ORALANTIVIRALS

•  ForHerpesZoster(shingles)treatment•  ForBell’sPalsytreatment•  Muststartwithin72hrsforbesteffect;preferablywithin24hrs

•  Acyclovir800mg5Xday•  Famvir500mgtid•  Valtrex1gramtid




NAME Steven Ferrucci AGE !!!

ADDRESS_____________________________________________________ DATE 6/6/66 !!

Rx Acyclovir 800mg #50 1 po 5x day

!

!!


MOREDRUGS

#GONNAVOMIT

ANTI-EMETIC

•  Phenergan25mgtabletsorsuppositories•  Phenergan12.5mgtablets•  Alsoavailableinsyrupandelixir•  1every4-6hoursasneededforN&V•  Cancauseincreasedsedation•  AlsoconsiderZofran8mgq8h

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NAME MARC BLOOMENSTEIN AGE !!!

ADDRESS_____________________________________________________ DATE 6/22/14 ! Rx Phenergan 25mg #20

1 po q 4-6h prn NV

!!

!REFILLS-- ! Dispense As Written Substitution Permissible!

SLEEPAIDS

•  ConsiderDiphendydramine25-50mg(Benadryl)availableOTC

•  Ambien5mgor10mgqhsprn– AmbienCR6.25mgor12.5mg– AllAmbienproductsareScheduleIV

•  Rozerem8mgqhsprn– Notacontrolledsubstance

DEALINGWITHOTHERPROFESSIONALS

•  Pharmacists•  DEAnumbers•  Callinginprescriptions

•  Insurancecompanies•  TalkingwithPCPwhennecessary

KEEPINGUP

•  Rxlist.com– Searchfordruginformation– Top300List

•  Centerwatch.com•  Epocrates.com•  Drugs.com•  Lexi.com– OrderDrugInformationHandbookPocketyearly– What’sNew•  NewDrugSection

THANKYOU

PEACEOUT

8/9/18 - mimhtraining.com

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