Post on 23-Jan-2021
Top Ten Oral Agentsand a Few other ThoughtsJ. JAMES THIMONS, O.D.,FAAO
MEDICAL DIRECTOR / OPHTHALMIC CONSULTANTS OF CONNECTICUT
JIMTHIMONS@GMAIL.COM
Disclosure
I am a consultant for or am on the Medical Advisory Board of: Allergan AlconAMO Advanced Vision Research InspireTLC Laser CenterCarl Zeiss MeditecSynemed
ANTI-VIRALS
ACYCLOVIR FAMVIR VALTREX
ANTI-VIRALS
CLINICAL APPLICATIONS ACUTE VS CHRONIC INFECTION
PRIMARY LESIONS
EPITHELIAL HERPES SIMPLEX
STROMAL HERPES SIMPLEX
HERPES ZOSTAR
HERPETIC IRIDOCYCLITIS
ANTI-VIRALS
SIDE EFFECTS RENAL FAILURE/ IMPAIRMENT
HYPERSENSITIVITY REACTIONS
FACIAL EDEMA
VISUAL HALLUCINATIONS
VARICELLA ZOSTAR-KERATITIS
PRIMARY INFECTION CHICKEN POX
VACCINATION RECOMMENDED BY AMERICAN ACAD of PEDIATRICS
RECURRENT INFECTION OPHTHALMIC INVOLVEMENT 10-255
OPHTHLAMIC ZOSTAR > OVER AGE 60
UNDER 40 50% IIMMUNOCOMPRIMISED
The Cyclines
Tetracycline, Doxycycline and Minocycline Isolated from Streptomyces
Effective against Gram +/ Gram -/Aerobic/ Anerobic/ Spirochetes/Rickettsia/Chlamydia
Similar action / different duration
Tetracyclines
Tetracycline (Sumycin) Doxycycline (Vibramycin) Coated doxycycline (Doryx)
Tetracycline (Sumycin)
Formulations 250mg, 500mg tablets/capsules: syrup 125mg/tsp
Dosages 250mg, 500mg q.i.d
Doxycycline (Vibramycin)
Formulations 50mg, 100mg capsules: 100mg tablet: suspension
25/tbs: syrup 50mg/tsp
Dosages 50mg, 100mg q.i.d
Oracia 40 mg sustained release/ regular
Periostat 20 mg
Most common use in dentistry
The Cyclines
Clinical Applications Brucellosis Rickettsia ( Rocky Mountain Spotted fever) Lyme Disease Chlamydia/ Trachoma Primary Meibomianitis Gonococcal Prophylaxis “Corneal melting” Syndrome Non Healing Corneal lesions Rosacea
The Cyclines
RCE PLD Lyme’s Microbial Keratitis Corneal “melt” syndrome
“How could I ever get mad at you”
GS a 33 y/o Caucasian female presented with a complaint of discomfort, watering and light sensitivity following blunt trauma.
PEX: VA: 20/20 OD – 20/30- OS SLE: 2 mm area of epithelial damage with staining
at 12:00 Occasional A/C cell 2+ injection
“How could I be mad at you”
Treatment: BCL 4th Generation FQ Acular PF
Symptoms resolved after 1 week of Tx Patient dismissed with instructions and Systane q4
hours Muro 128 Unguent hs
“ How could I be mad at you”
Patient returned to office 10 weeks later with c/o AM pain and return of symptoms.
D/C gtts after 4 weeks PEX:
VA: 20/30 SLE: As shown 2+ injection
Recurrent Erosions
Medical ManagementNocturnal lubricationNocturnal hypertonic salineBandage contact lensTreat underlying conditions
Recurrent Erosions
Contributing FactorsDry eyesBlepharitisExternal disease / tear
film abnormalities
Lipid Secretion: Meibomian Glands
Meibomian gland dysfunctionTransillumination ofmeibomian glands
Recurrent Erosions
Treatment Doxycycline 50 mg po bid
OM3’s
Azasite qd hs
BCL 30 day wear
Restasis
Omega 3 Fatty Acids
Re-esterized OM3 Ethyl Ester
Interim Analysis
Tear Osmolarity (mOsm/L)
Omega-3
Placebo
325.82
320.30
Wk 0 Wk 6 Wk 12
316.79
318.85
312.42
320.70
Interim Analysis• Corneal staining (measured on 0-
5 scale)
Chart1
Wk 0Wk 0
Wk6Wk6
Wk12Wk12
Omega-3
Placebo
1.5
1.67
0.97
1.23
0.44
1.25
Sheet1
Wk 0Wk6Wk12
Omega-31.50.970.44
Placebo1.671.231.25
Sheet1
Omega-3
Placebo
Sheet2
Sheet3
Interim Analysis
Ocular Symptom Disease Questionnaire
Omega-3
Placebo
34.95
22.05
Wk 0 Wk 6 Wk 12
22.92
15.44
15.54
15.93
Interim Analysis
Omega Index levels (%)
Omega-3
Placebo
4.48
4.79
Wk 0 Wk 12
8.49
4.49
Re-Esterified OM3’s
: http://prnomegahealth.com/glaucomasociety/
http://prnomegahealth.com/glaucomasociety/
A Challenger for the Title
Kashkouli, MB BJO 8/2014 110 patients with MGD randomly assigned
to: Doxy 200mg/ day x 1 month Azithromycin 500mg x1 then250mg x4
Significant improvement in both groups Bulbar hyperemia and ocular surface staining
better in Azith group Azith group showed significantly betteroverall
clinical response Doxy group showed increased GI symptoms
Take Your Time: It’s Worth it!
Fraunfelder, FW et al: Cornea 2010 12 subjects/ failed on initial therapy of lubrication/
NaCl Treated with bandage lens x 3 months 75 % had complete resolution at one year from
initial Tx 2 had symptoms but no signs 1 patient had symptoms and signs
The Way to a Man’s Eyelid is Thru His Stomach! BMJ Aug 2013 44 randomized trial meta-analysis 22 trials/ 5000 patients
Sequential therapy ( 2x daily PPI with Amoxicillan) was significantly better than triple therapy ( PPI, Clarithromycin, Metronidizole)
87% vs 72% outcome 14 trials 2750 patients
84% vs 75% Resitent to Tx sub Levofloxacin
Oral Antibiotics
PCN’s Cephalosporin’s Macrolides
Wow! What Happened While I was Asleep?
JR a 23 year old Caucasian female awoke with a pain, swelling and a pulsing ache over her left eye.
Pt. denies h/o trauma, prior occurrence or vision loss.
PEX: VA 20/20 OD , 20/20 OS EOM: Full without pain VF: CFTFC/ OU
Wow: What Happened While I Was Asleep?
Ta: 18/19 SLE: 2+3 Tender lid edema. Cornea clear,
AC=D&Q. Negative discharge. DFE: 0.2 OU Dx: ? Tx:
ular Bacterial Disease
Posterior Blepharitis Hordeola Canaliculitis Conjunctivitis Keratitis Dacryocystitis Dacroadenitis Preseptal/orbital cellulitis Endophthalmitis
Bacterial Flora of the Normal Eye/Adults
Staphylococcus epidermidis 75-90%*Diphteroids (C. xerosis) 20-33%Staphylococcus Aureus 20-25%*Streptococcus (S. viridan) 2-6%Hemophilus influenza 3% or moreStreptococcus pneumoniae 1-3%*Gram negative rods 1% or more*Pseudomonas aeruginosa 0-5%*
* Dominant organisms in microbial keratitis
Body depots of bacterial organisms
Skin: Lids/hands: Staph/Gr. (+) Nose/nasopharynx: Staph and GR (+) Kids: Hemophilus Oropharynx: Staph and StrepGr (+) Mouth: Strep/Bacteroides Stomach: Helicobacter pylori and rosaceae Small Intestine: Gr (+) cocci and bacilli Large intestine: Greatest conc of bacteria in
body (10 organisms/gm) anerobes-enterobacteria, enterococcus feacalis, E. coli
Genito-urinary tract: Chlamydia, E. coli, Neisseria gonorrhea (Ophthalmia neonatorum)
12
Bacterial conjunctivitis
In adults, 75% of cases caused by Gram positive pathogens Staphylococcus epidermidis, S. aureus,
Streptococcus pneumoniae
Very common in children under 6 years Causal agents of pediatric cases:
42% Haemophilus influenzae
35% S. pneumoniae
Everett et al, 1995Block et al, 2000
Common Ocular PathogensGram (+)
Staph epidermidis
Coagulase negative
Opportunistic pathogen
Frequent cause of CL keratitis
Normal flora
Chronic bleparitis
Staph aureus
Coagulase positive
Methacillin resistant strain
Exotoxins
Inflammatory disease
Abscess formation
Severe keratitis
Strep pneumonaeEnzymes/virulenceSeen in cold climatesPerforate in 7 daysassociated with erysipilus cellulitis
Strep Species
Important Penicillins
Ampicillin: Broad spectrum oral-QID dosing Amoxicillin: Pro-drug of Ampicillin, improved
absorption with lower GI side-effects Cloxacillin/Dicloxacillin: Intrinsic beta-
lactamase resistance Augmentin: Amox + Clavulanate Methicillin: IV prep for penicillinase producers Amp + Sulbactam: Unasyn: IV
Ticarcillin + Clavulonic acid: IV better penicillinase protection than methacillin
Gram (-) species
Pseudomonas Hemophilus Klebsiella Serratia Moraxella Neiserria
AugmentinIndications/Dosage forms
Indications: Preseptal cellulitis Dacryocystitis Pediatric Hemophilus Amoxicillin + Clavulanate@@@@ Dosage forms: 500 or 875mg tablets BID 125 or 250mg/5cc pediatric suspension
AugmentinAmoxacillin/Clavaulanate
Broad spectrum penicillin (Staph, Strep, Hemophilus
Effective against penicillinase producers-clavulanate blocks penicillinase@@@
High therapeutic index Bacteriocidal Low GI side-efffects Safe in pregnancy Watch out for allergy Cheap***
Plan B: The cephalosporins
Mechanism: Same as penicillin Bacteriostatic Low toxicity 3% allergic to pen are allergic to Ceph. Better penicillinase resistance than
penicillins
Know your generations
First Generation: Good GR (+) activity against penicillinase producers/poor Gr (-) activity especially Hemophilus (children)
Cefadroxil: Duricef-PO Cephazolin: IV- Ancef- Keratitis Cephalexin: PO-Keflex Cephadrine: PO- Velosef
tivity,
us Cefaclor: PO-Ceclor Cefuroxime: PO-Ceftin
Third Generation: Reduced GR (+) activity (Staph sp) with marked Gr (-) activity
Cefixime: PO- (Suprax) Cefpodoxime: PO - Vantin Cefprozil: PO - Cefzil
Pre-Septal Considerations
JAMA 2013 Dec. Dual cohorts of 95,000 each, older
adults (mean 76) who were users of Calcium Channel Blocker’s
Clarithromycin (inhibitsCYP3A4 which can cause increased CCB levels) vs: Azithromycin ( non inhibitor)
Measured for 30 days post treatment Risk for hospitalization 0.44% vs 0.22% due
to acute kidney injury All cause mortality 1.02% vs.0.59%
Macrolides
Erythromycin (E-Mycin) Azithromycin (Zithromax, Z-PAK)
Erythromycin (E-Mycin)
Formulations 250mg, 500mg tablets
Dosages 250mg, 500mg q.i.d., b.i.d
Azithromycin (Zithromax)
Formulations 250mg, 500mg 600mg tablets: suspension
100mg/5ml, 200mg/ml Z-PAK six 250 mg tablets, TRI-PAK three 500mg tablets
Dosages1 gm one dose administration for Chlamydia: 500mg
q.d. followed by 250mg q.d for four days
Fluoroquinolones
Levofloxacin (Levaquin) Ciprofloxacin (Cipro) Gatifloxacin (Tequin) Moxifloxicin (Avelox)
Corticosteroids
Prenisone (Deltason) Methylprednisolone (Medrol)
Levofloxacin (Levaquin)
Formulations 250mg, 500mg and 750mg tablets 25mg/ml oral
suspension
Dosages 250mg to 750mg q.d.
Ciprofloxacin (Cipro)
Formulations 100mg, 250mg, 500mg, 750mg and 1000mg tablets
Dosages 500 mg to 750mg b.i.d.
Gatifloxacin (Tequin)
Formulations 200mg and 400mg tablets
Dosages 400mg q.d.
Moxifloxicin (Avelox)
Formulations 200mg and 400mg tablets
Dosages 400mg q.d.
Steroids
99 % topical use in eye care Medrol Dose Pack most common Pred Forte Generic since January 2009 Lotemax/ Alrex & Durezol
Corticosteroids
Corticosteroids
Prenisone (Deltason) Methylprednisolone (Medrol)
Prednisone (Deltason)
Formulation 2.5mg, 5mg, 10mg, 20mg and 50mg tablets;
5mg/5ml solution/syrup
Dosage Varies based on condition
Methylprednisolone (Medrol)
Formulation 2mg, 4mg, 8mg, 16mg, 24mg and 32mg tablets
Medrol Dose Pak 21 4mg tablets
Dosage Varies based on condition
Clinical Case Examples
Scleritis Dermatitis Severe anterior uveitis Posterior uveitis Inflammatory preseptal cellulitis Progressive thyroid eye disease DLK
Interesting Facts
In steroid responders, onset of IOP elevation occurs after about two weeks of use
Time of onset often longer for systemic steroids Complex pathophysiologic factors result in increased
resistance to aqueous outflow
Steroids
99 % topical use in eye care Medrol Dose Pack most common Pred Forte Generic since January 2009 Lotemax/ Alrex & Durezol
STEROIDS
ORAL vs IV ADMINISTRATION INITIAL DOSE - 1mg/kg/day STANDARD TAPER
INITIAL THERAPY 2-3 DAYS, THEN TAPER AS INDICATED FOR CLINICAL RESPONSE
ALTERNATE DAY THERAPY- LONG TERM Tx- DOUBLE DOSE QOD THROUGH TAPER
STEROIDS
INHIBIT PROSTAGLANDIN AND LEUKOTRIENE ACTIVITY BY BLOCKING ACTION OF ENZYME PHOSPHOLIPASE A2.
Steroids
Oral vs. IV administration Initial dose determination (1mg/kg/day) Standard taper vs. alternate day therapy
Standard taper - start initial dose, monitor in 2-3 days, then taper as appropriate for clinical response
Alternate day therapy - for longer term therapy (more than 2-3 weeks), give double dose every other day, continue pattern throughout tapering process
Prednisone - Initial dose typically in 60-100 mg range as per above
Clinical Case Examples
Scleritis Severe anterior uveitis Posterior uveitis Inflammatory preseptal cellulitis Progressive thyroid eye disease DLK
Femtosecond Lasers and Keratomes
Photodisruption
Thousands of laser pulses are connected together in a spiral pattern to create a cleavage plane
DLK – Interface/edge Inflammation Cause(s) Too much energy (usually greater than 3.5uj) Edge angle too flat (usually less than 45° to 50°) Not enough topical steroid
Management Reduce horizontal and/or side cut energy Steepen edge angle (> 50° to 60°) Pre–peri–post op steroids to reduce cellular
infiltrates Post op meds generally same as mechanical
keratectomy
“Mirage” Edema
6 KHz
CASE #5
A 37-year-old white male was referred s/p lasik x 3 weeks with h/o decreased acuity OU (OD>OS).
Onset was gradual but patient has been symptomatic since Tx with pain/ou.
Surgical history revealed bilateral abrasions at the time of the procedure involving the inferior half of the cap and bed.
Patient has had two lifts and scrapes in two weeks
CASE #5
Physical exam revealed BVA 20/200 OD 20/100 OS.
External shows minimal injection & OU. SLE revealed 2+-3 epithelial irregularties/OU with
3+4 cystic changes, pseudodendrites and frank defects.
Ta- 18/20 @ 10
Case #5
Additionally the patient demonstrated 3+ interface haze OU contiguous with and extending beyond the area of epithelial change.
AC occasional cell. Remainder of exam WNL. Current medications: Pred Forte q3hour
IOP after DSEK
Price,FW AJO 2008 50 eyes/38 patients Mean CCT 701 microns Pnemotonometry: 20.3 mmHg +/-4.5 mmHg Pascal: 19.8 mmHg +/- 4.4 mmHg Goldmann: 15.9 mmHg +/- 4.9 mmHg If IOP is elevated with Goldmann it is probably real
Steroids vs.Immunomodulation Ashcroft DM; BMJ Mar 2005 Meta-analysis 25 trials Tacrolimus (Protopic) / Pimecrolimus
(Elidel) vs. Potent and Mild steroids Tacrolimus = Potent steroid > Mild Pimecrolimus< Potent Steroid FDA “Black Box” Recommended use:
Facial area( steroid atrophy) Pulse therapy Intolerant of steroids
NSAID’S
IBUPROFEN KETOROLAC INDOMETHACIN NAPROXEN TRAMADOL CELEBREX
NSAID’S
CLINICAL APPLICATIONS ANALGESIA
ANTI-INFLAMMATORY
MUSCULOSKELATAL/ MYOSITIS
ACUTE GOUT
DYSMENNORRHEA
CME
NSAID’S
CORNEAL OPACITIES( WHORL) TINNITUS FLUID RETENTION EPISTAXIS BREAST CHANGES ANEMIA/BLEEDING CONSTIPATION
NSAID’S
CLINICAL APPLICATIONS ANALGESIA
ANTI-INFLAMMATORY
MUSCULOSKELATAL/ MYOSITIS
ACUTE GOUT
DYSMENNORRHEA
CME
NSAIDS , H Pylori and Gastric Ulcers
Lancet 2002 Jan 5; 359: 14-22 1625 NSAID users
Peptic ulcer disease 42 % H Pylori patients
26% of non-infected patients
Peptic ulcer disease 36 % of NSAID users
8% of non users
Risk of bleeding ulcer (6.1x> in H Pylori on NSAIDS0
Narcotic Agents
Effective for severe acute pain Patient response variability due to individual
sensitivity of opioid receptors No addiction likely with short term use Dosage varies with drug used and patient Adverse effects is usually the limiting factor in
usage
Narcotic Agents
Hydrocodone (Schedule III) (Lortab, Vicodin) 2.5-7.0mg tid-qid with acetaminophen
Narcotic Agents
6 times more potent than codeine Less gastrointestinal problems Less sedation ?? euphoria
Important notification for patients
Drowsiness Dizziness Blurred vision Nausea/vomiting/constipation Take with food to avoid GI distress Avoid Etoh or other CNS agents Breathing distress
Contraindications
Bronchial asthma COPD Emphysema Pregnancy Hypersensitivity Prior addiction Renal/Liver dysfunction H/O Etoh use, Concurrent use of
CNS agents(Tricyclic antidepressants, Phenothiazines)
Narcotic agents
Directly affect opioid receptor Agonist, partial agonist, or mixed Bind to opioid receptors in brainstem, corticol
areas and spinal cord Mimic endorphins, producing a morphine like
effect whether natural or synthetic
Narcotic Agents
Effective for severe acute pain Patient response variability due to individual
sensitivity of opioid receptors No addiction likely with short term use Dosage varies with drug used and patient Adverse effects is usually the limiting factor in
usage
Narcotic Agents
Hydrocodone (Schedule III) (Lortab, Vicodin) 2.5-7.0mg tid-qid with acetaminophen
Narcotic Agents
6 times more potent than codeine Less gastrointestinal problems Less sedation ?? euphoria
Important notification for patients
Drowsiness Dizziness Blurred vision Nausea/vomiting/constipation Take with food to avoid GI distress Avoid Etoh or other CNS agents Breathing distress
Contraindications
Bronchial asthma COPD Emphysema Pregnancy Hypersensitivity Prior addiction Renal/Liver dysfunction H/O Etoh use, Concurrent use of
CNS agents(Tricyclic antidepressants, Phenothiazines)
Top Ten Oral Agents�and a Few other ThoughtsSlide Number 2Slide Number 3DisclosureANTI-VIRALSANTI-VIRALSANTI-VIRALSSlide Number 8Slide Number 9Slide Number 10Slide Number 11Slide Number 12Slide Number 13Slide Number 14Slide Number 15Slide Number 16Slide Number 17Slide Number 18VARICELLA ZOSTAR- KERATITISSlide Number 20Slide Number 21Slide Number 22The CyclinesTetracyclinesTetracycline (Sumycin)Doxycycline (Vibramycin)The CyclinesThe Cyclines“How could I ever get mad at you”Slide Number 30Slide Number 31“How could I be mad at you”“ How could I be mad at you”Slide Number 34Recurrent ErosionsRecurrent ErosionsSlide Number 37Slide Number 38Lipid Secretion: Meibomian GlandsRecurrent ErosionsOmega 3 Fatty AcidsInterim AnalysisInterim AnalysisInterim AnalysisInterim AnalysisRe-Esterified OM3’sA Challenger for the TitleTake Your Time: It’s Worth it!The Way to a Man’s Eyelid is Thru His Stomach!Oral AntibioticsWow! What Happened While I was Asleep?Wow: What Happened While I Was Asleep?Slide Number 53Ocular Bacterial DiseaseBacterial Flora of the Normal Eye/AdultsBody depots of bacterial organismsBacterial conjunctivitisCommon Ocular Pathogens�Gram (+)Important PenicillinsGram (-) speciesAugmentin�Indications/Dosage formsAugmentin�Amoxacillin/ClavaulanatePlan B: The cephalosporinsKnow your generationsSecond Generation: �Greater Gram (-) activity,�especially HemophilusPre-Septal ConsiderationsMacrolidesErythromycin (E-Mycin)Azithromycin (Zithromax)�FluoroquinolonesCorticosteroidsLevofloxacin (Levaquin)Ciprofloxacin (Cipro)Gatifloxacin (Tequin)Moxifloxicin (Avelox)SteroidsCorticosteroidsCorticosteroidsPrednisone (Deltason)Methylprednisolone (Medrol)Clinical Case ExamplesInteresting FactsSteroidsSTEROIDSSTEROIDSSteroidsClinical Case ExamplesFemtosecond Lasers and Keratomes Slide Number 89DLK – Interface/edge InflammationSlide Number 91CASE #5CASE #5Case #5IOP after DSEKSteroids vs.ImmunomodulationNSAID’SNSAID’SNSAID’SNSAID’SNSAIDS , H Pylori and Gastric UlcersNarcotic AgentsNarcotic AgentsNarcotic AgentsImportant notification for patientsContraindicationsNarcotic agentsNarcotic AgentsNarcotic AgentsNarcotic AgentsImportant notification for patientsContraindications