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Gtts, Ungs, Tabs COMPREHENSIVE REVIEW OF DROPS, OINTMENTS, AND PILLS THAT YOUR DOCS RX FOR THE EYES Mindy J Dickinson, OD Midwest Eye Care, PC Learning Objectives Abbreviation Review Color Coded Caps Associated with each Class of Drops Basic Dosage and Side Effects of the Drug Classes Topical and Oral Agents Become Familiar with Which Products Belong to Which Class of Drugs 1) 2) 3) 4) 5) 6) 7) 8) Antibiotics Anti-Inflammatories Combination Drops Antivirals Anti-Allergy Agents Eye Pressure Lowering Agents (Anti-Glaucoma) Dilation/Cycloplegic Drops Other Abbreviation Review Gtt (gutta) Ung (unguentum) Tab OD (oculus dexter) OS (oculus sinister) OU (oculus uterique) PO (per os) Dosing Schedules QD BID TID QID QHS QOD Q15 min, Q1h, Q2h,… PRN Things that must be on a Rx 1. 2. 3. 4. 5. 6. 7. 8. Drug Name (brand name or drug name) Recommended Dosage Dispense Quantity Number of Refills Generic allowed or not Dr’s Signature Date Dr’s Contact Information Cap Color-Coding Most drug classes have a special color of cap to signify what it does Antibiotics: tan Steroids: pink NSAIDS: grey Dilation drops: red Glaucoma: turquoise, yellow, orange, purple, blue Helpful for patient education Helpful when taking patient history to understand what drops they are using and how often ** Not all generic drops will follow this rule of thumb Antibiotic Drops Purpose: kill bugs Used for corneal ulcers, bacterial conjunctivitis, blepharitis, prevent infection in setting of recent eye surgery, corneal abrasions, foreign bodies, etc Cap Color: tan Dosage: variable May be as low as BID Don’t usually dose any lower due to increased chance of bug resistance Most frequently is QID May be as much as Q15 min x 4 doses (a loading dose) or Q1h Before Rxing any Antibiotics… Always confirm if patient has any known allergies !! Common: penicillin, sulfa **Role of technician: must have this documented in every chart that you reviewed allergies with patient Antibiotics ZYMAXID, VIGAMOX (TID), MOXEZA (BID) , BESIVANCE (TID) Newest, “strongest”, brand name only, most $$$ No ung possible Usually save for more serious infections, corneal ulcers CILOXAN (ciprofloxacin), OCUFLOX Older, still broad spectrum, generic, less $ CILOXAN ung – but no generic, very $ TOBREX (tobramycin) Less $, Ung available as well POLYTRIM (polymixin B sulfate and trimethoprim) Great for conjunctivitis, safe in small children, cheap AZASITE Azithromycin drop, very $$, mostly used for blepharitis, conjunctivitis (BID x 2 d, QD x 5 d) GENTAK (gentamycin) Irritating to ocular surface, often from PCP or ER docs Ung available as well Can have fortified antibiotic drops compounded as well Specialty pharmacy makes extra strength sterile drops Usually in stetting for serious infection – corneal ulcer, endophthalmitis Antibiotic Ungs Benefits: Adhere longer to ocular surface Offer increased comfort since greases up ocular surface so less friction between eyelid and cornea May be dosed less often since sits on eye longer Cons: Blur vision May be more difficult to instill ** may be helpful role as the technician to offer tips to patients/parents on how to instill ointment Common ungs: Polysporin (polymixin B/bacitracin) CILOXAN TOBREX (tobramycin) GENTAK (gentamycin) Oral Antibiotics Used for ocular/peri-ocular infections where drops not going to be effective Need to make sure not allergic to Pre-septal cellulitis, hordeolum (stye) Eyelid disease (chronic blepharitis, meibomitis) Peri-ocular abcesses Chlamydial conjunctivitis In fractured orbit to prevent spread of sinus germs ? Sinus infection causing peri-orbital pain Oral Antibiotics Doxycycline Used for blepharitis/meibomitis, recurrent styes Has an enzyme in it that cleans the glands out from the inside and reduces inflammation in the eyelid glands as well Dosage: May get as a convenience pack ($$) that also includes eyelid scrubs, heated goggles 20, 40 , 50, 100 mg tablets 1 tab po QD x 30 days or 1 tab po BID x 2 weeks, then QD x 2 weeks May dose for several months at a time so may need refills ALODOX, OCUDOX Cannot give if pregnant or if a child (permanently discolors teeth) Side effects: GI upset More likely to sunburn Females: ? Increased risk for yeast infection, reduced efficacy of BCP Minocycline 50 or 100 mg – good alternative if doxycycline not available Oral Antibiotics Azithromycin Chlamydial conjunctivitis – 1 gram tab po x 1 dose ZPAK – 1 day, 3 days or 5 days Cannot give if heart beat issues Augmentin (amoxicillin + clavulanate) Cannot give in PCN allergy 500 mg PO BID or TID or 875 mg PO BID Amoxicillin Cannot give if PCN allergy 250-500 mg PO TID or 500-875 PO BID Keflex 250 mg QID or 500 mg BID Cipro 250 mg QID or 500 mg BID fluoroquinolone Bactrim DS (trimethoprim sulfamethoxazole) Cannot give in sulfa allergy 1 tab po BID Antiviral Drops Purpose: kill viruses on ocular surface Used for Herpes Simplex dendritic keratitis, possibly viral conjunctivitis Cap color: white 2 options: VIROPTIC (trifluridine) – Older, not as expensive (still >$100), more toxic/irritating to eye Dosage: variable - Q2hr while awake, QID, sometimes tapered ZIRGAN Newer, $$$$, comes in tube, more gel-like, not all pharmacies carry, much less toxic/irritating to eye Dosage: 5x per day until ulcer healed, then reduce to TID x 1 more week Oral Anti-Virals Purpose: Used to reduce recurrences of Herpes Simplex (Cold Sore) flare-ups Used upon first evidence of a Herpes Zoster (Shingles) outbreak Options: ZOVIRAX (acyclovir) VALTREX (valacyclovir) 400 mg BID long term for HSV 800 mg 5x/day x 1 wk for active Shingles can get made into suspension for a child 500 mg QD long term for HSV 1000 mg TID x 1 wk for active Shingles can get made into suspension for a child FAMVIR 500 mg QD long term for HSV 500 mg TID x 1 week for active Shingles Anti-Inflammatory Drops - Steroids Purpose: reduce inflammation Used for conjunctival/corneal/anterior chamber inflammation – perhaps related to allergies, chemical exposure, recent infection, trauma, contact lenses or surgery; iritis/uveitis; as both prevention and treatment of post-operative swelling in front of eye and/or in macula; reduce chance of rejecting transplanted corneal tissue Cap Color: pink Dosage: variable QD all the way up to Q1hr Often start more aggressive and then slowly taper Steroids Facts Most are suspensions – separate in bottle MUST SHAKE before each use particularly generics Cloudy in color, “milk” Usually important to taper, not stop suddenly Potential Side Effects: Increase in eye pressure Early cataract formation Increased risk of infection Bad taste in back of mouth after instilling Steroid Eye Drops (+) Stongest DUREZOL PRED FORTE, OMNIPRED (prednisolone acetate 1%) Suspension – MUST SHAKE Brand name thought to penetrate into eye better LOTEMAX Emulsion – only one you don’t have to shake More expensive, but more potent Suspension – must shake Not as potent, but less potential side effects Can get in gel or in ung ($) Often used more in more chronic situation Preventing an iritis flare up, anti-rejection, dry eye syndrome ALREX, FLAREX, VEXOL, FML (fluometholone 0.1%) Suspension – must shake Weakest, but least side effects Often in less inflamed, more chronic conditions Indicated for allergic conjunctivitis, dry eye syndrome Weakest Oral Steroids Used in severe allergic and inflammatory conditions where drops not effective enough Immune-mediated corneal melts/ulcers, Scleritis/Severe Episcleritis, Severe Uveitis (both in front or back of eye), Inflammatory Orbital Pseudotumor , Giant Cell Arteritis (optic nerve swelling) Optometrists cannot Rx oral steroids in all states Side Effects a big deal Increase blood sugars (concern in diabetics) Change in mood, sleeping habits, appetite Weight gain, acne, outbreaks of other problems (cold sores, shingles, genital herpes) Prednisone: 2, 5, 10, 20 mg tab MEDROL DOSEPAK: (21 - 4 mg tabs, directs you to take 6 the first day and reduce to 1 per day over 6 days) – “take as directed” Combination Antibiotic/Steroid Drops Purpose: offer both anti-infective and anti-inflammatory properties in single drop Used for settings when need antibiotic protection such as missing skin on eye, but need to calm down swelling, Corneal abrasion, chemical burns, foreign body, traumatic iritis, some conjunctivitis Not supposed to be used when active infection is not yet controlled as steroid will reduce ability of immune system to fight it off and can make it worse Corneal ulcers ! Cap Color: pink or white Dosage: Usually QID or perhaps up to Q2hr Combinations of Antibiotic/Steroid TOBRADEX ST (tobradex) (tobramycin/dexamethazone) Drops or ung Need to be careful with name – tobrex vs tobradex – big deal if you rx it wrong and gave a steroid to someone that should not have it!! More $ MAXITROL (neomycin/polymixin B/dexamethasone) Drops or ung Much less expensive Higher chance of irritation/allergy to neomycin Non-Steroidal Anti-Inflammatory Drugs NSAIDs Purpose: to reduce inflammation of ocular tissue, reduce pain, Used for surface inflammation such as episcleritis, pain associated with corneal abrasions/recurrent corneal erosions Used for the prevention/treatment of pain and inflammation associated with ocular surgery (cataract, refractive surgery) Cap Color: gray Dosage: Variable – QD to QID Topical NSAIDs ILEVRO, PROLENSA, BROMDAY Newest, $$, QD dosage, great penetration into back of eye Usually dosed day before cataract surgery, day of surgery, and 2 weeks after NEVANAC TID dosage, also great penetration into back of eye XIBROM BID dosage ACUVAIL PF vials, BID, meant for post-surgery care ACULAR LS (Ketoralac) QID, Generic, cheap, stings like crazy Flurbiprofen QID, Generic, cheap, stings like crazy Oral NSAIDs OTC: ADVIL, MOTRIN (ibuprofen) Pain associated with corneal abrasions/foreign bodies, etc Reduce inflammation associated with conjunctivitis Reduce inflammation associated with episcleritis Dosage: 600 mg po TID with food In Rx form can get 800 mg tablets, otherwise 200 mg tablets OTC ALEVE (naproxen) Aspirin 81 mg (baby) – reduce risk of stoke, heart attack 325 mg TYLENOL (acetaminophen) Does not thin blood Pain associated with blunt trauma to eye that has a hyphema (since don’t want them to rebleed) Patients who cannot take ibuprofen Rx only: Indomethacin Used for more severe inflammation – severe epicleritis/scleritis/orbital pseudotumor Anti-Allergy Drops Purpose: to treat itchy, watery, puffy, red eyes associated with allergic conjunctivitis Work either as anti-histamine or as a mast cell stabilizer Cap color: white Dosage: QD or BID/PRN Some Rx only, some OTC Beneficial over OTC Visine-A, Naphcon A, etc products Side Effects: sting, bad taste in back of mouth Anti-Allergy Eye Drops PATADAY QD, more $, very effective, little to no sting PATANOL BID BEPREVE BID OPTIVAR (azelastine) Only rx with generic option, BID ELESTAT BID LASTACAFT QD, stings ZADITOR/ALAWAY (ketotifen) OTC, BID, many additional names out there, stings, not always as effective, but cheaper than most ALOCRIL, ALOMIDE, cromolyn Less often used, have to be dosed QID Glaucoma Drops Purpose: to lower intraocular pressure and thereby reduce the risk of further nerve damage by glaucoma Work by either decreasing aqueous production and/or increasing aqueous outflow Cap color: depends on mechanism of action Dosage: depends on which class of drug (QD, BID, TID, QID) Side Effects: depends on which class of drugs Glaucoma Drops Prostaglandin Analogs Increase outflow of aqueous humor Brands: • • • • • XALATAN (latanoprost) TRAVATAN Z LUMIGAN ZIOPTAN (new and preservative free, $$$) RESCULA (only one with dosing BID) Cap Color: turquoise Dosage: 1 gtt QHS “First line” therapy, 25-30+ % IOP reduction Side effects: darkening of iris and skin around eye, thickening/lengthening of lashes, red eye, inflammation in eye Glaucoma Drops ßeta- Blockers Decrease production of aqueous humor Brands Timolol 0.25% or 0.5% BETIMOL, ISTALOL, TIMOPTIC XE (gel) TIMOPTIC in OCUDOSE (preservative free vials) BETAGAN, BETOPTIC Cap Color: yellow Dosage: 1 gtt QAM or 1 gtt BID 25-30% IOP reduction Can be 1st line $, Cheap, generic available Side effects: difficulty breathing, decreased heart rate don’t give if history of COPD, emphysema, asthma, bradycardia Glaucoma Drops Alpha Adrenergics Decrease production of aqueous humor Brands: • ALPHAGAN P (0.1%) • Brimonidine (generic – 0.15%, 0.2%) Cap Color: Purple, if brand name also has a green bottle Dosage: 1 gtt BID or TID 15-20% IOP reduction Great additional med, also use post-operatively for IOP spikes Side effects: red irritated eyes, itching, follicular conjunctivitis Particularly more likely in generics and at higher concentration Glaucoma Drops Carbonic Anhydrase Inhibitors (CAIs) Decreases production of aqueous Brands: • AZOPT • TRUSOPT Cap Color: Orange Dosage: 1 gtt BID or TID 15-20% IOP reduction 2nd or 3rd med add – not usually mono therapy Side Effects: red irritated eyes, burn like crazy, unpleasant taste Avoid if serious kidney problems, allergy to sulfa Glaucoma Drops Combination Drops 2 medicines in 1 bottle More effective on IOP without much more work on patients behalf, increases compliance Brands: COSOPT (timolol and trusopt), COSOPT PF (preservative-free) Generic available still $, stings COMBIGAN (timolol and alphagan) Newer, no generic, most find to be comfortable to use • Cap Color: dark blue • Dosage: 1 gtt BID • Side Effects: due to timolol cannot give if breathing problems (COPD, asthma, bradycardia) SIMBRINZA (brinzolamide and brimonidine) Newest, no generic, only one without timolol • Cap Color: white • Dosage: 1 gtt BID or TID Glaucoma Drops Sympathomimetics Increase outflow by pulling on drain to help it open Brands: • Pilocarpine (1, 2, 4%) • Carbachol Cap Color: Green Dosage: 1 gtt BID to QID Very rarely use any more now that have more options Side Effects: miosis (constrict) of pupil, peripheral retina pathology (tear, RD), accommodative spasm so eyes shift near-sighted, headache Oral Meds to Lower Eye Pressure Used when IOP rises suddenly to a very high level (50+) Acute glaucoma – angle closure Severe inflammation – sometimes see in Shingles Recent Trauma – blood blocking drain Not meant for long term maintenance Carbonic Anhydrase Inhibitors Decreases aqueous (and CSF) production Diamox 250 mg 1 tab PO QID or 500 mg Sequel 1 tab PO BID Neptazine 25 mg 1 tab PO QD or BID or TID Optometerists in some states may not be able to Rx this Side Effects: tingling of skin, metallic taste, cannot give if kidney disease Dilation/Cycloplegic Drops Purpose: 1) To dilate pupil to allow better viewing of the back of the eye 2) To relax ciliary muscle and thereby relax accommodation – allowing full hyperopic refractive error to be found on refraction (use for examining children) 3) To treat amblyopia (lazy eye) 4) To temporarily paralyze the iris and ciliary muscle a) b) to reduce pain in setting of trauma/inflammation (Corneal abrasion/foreign body, chemical burn, welding burn, iritis, recent surgery, etc) to reduce chances of inflamed iris from sticking to the lens behind it and forming synechiae Dilation/Cycloplegic Drops Cap Color: red Dosage: variable Depends of duration of action of the drug Side Effects: Stinging upon instillation, photophobia, blurred near vision Dilation/Cycloplegic Drops MYDRIACYL (tropicamide) 0.5% or 1 % Best dilator, some limited effect on accommodation (approx 4 hrs) Used in office, not really Rx’d MYDFRIN, NEO-SYNEPHRINE (phenylephrine) 2.5% or 10% Aides in dilation, not really any effect on accommodation Use with tropicamide, not by itself Also constricts blood vessels on surface of eye – can help determine how deep inflammation is in setting of episcleritis vs. sclertitis 10% rarely used, can increase blood pressure, need to punctally occlude, used to break synechiae in setting of bad uveitis Dilation/Cycloplegic Drops CYCLOGYL (cyclopentolate) Most often used for pediatric eye exams to relax accommodation Get more accurate refraction – especially if concern for eye turn 0.5% (< 1 year old); 1% (> 1 year old) – 1 gtt OU, repeat 5 min later Takes 30-40 minutes to fully relax accommodation and lasts approx 12-24 hrs Can also be used post trauma/surgical procedure – 1 gtt in office or up to QID Scopolamine (0.25%) 1 gtt TID Used for paralyzing iris/ciliary muscle in trauma/inflammation Homatropine (5%) 1 gtt BID Used for paralyzing iris/ciliary muscle in trauma/inflammation Lasts for 24 hours + Atropine (1%) 1 gtt QD Used for treatment of amblyopia Used for paralyzing iris/ciliary muscle in trauma/inflammation/or post surgery Dilation/loss of accommodation last approx 1 week! Other RESTASIS Used for treating inflammatory forms of dry eye syndrome Goal is to increase patient’ tear production Not a quick fix – can take 3-6 month to get effects Comes in “single use” preservative-free vials Dosage: 1 gtt BID OU Write Rx as “30 vials = 1 box = 1 month” with refills $, rebates often available, cheaper if can use vial more than once Side Effects: redness, burning/stinging upon instillation ** role of technician in patient education – how to use vials, that it takes a while to work, that it will likely sting, try artificial tears first, stick with it for at least 3 months Other MURO (Sodium Chloride) OTC 2% or 5% drops – 1 gtt QD up to QID 5% ung – apply QHS Used to dehydrate cornea in setting of corneal edema Fuch’s dystrophy Post-Operatively Ung also used to help reduce chances of recurrent corneal erosions Drops sting, ung does not Artificial Lubricants gtts, gels, ungs – OTC, not going to cover here FUN at “The Heart” Dosage: as much as possible PRN Refills: unlimited No expiration Mindy J Dickinson, OD