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ORAL MEDS AND THE EYE

ORAL MEDS AND THE EYE. Jill Autry, OD, RPh Eye Center of Texas, Houston drjillautry@tropicalce.com. Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D.

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ORAL MEDS AND THE EYE

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  1. ORAL MEDS AND THE EYE Jill Autry, OD, RPh Eye Center of Texas, Houston drjillautry@tropicalce.com

  2. Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D.6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333 (281)277-1010 450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815 NAME AGE ADDRESS_____________________________________________________DATE Rx REFILLS--

  3. NON-CONTROLLED Rx • Doctor name/address/telephone # • Patient name • Address • Added by pharmacist • Patient age • Usually only put if pediatric Rx • Date • Good for one year from date of issue • Drug info area • Refill line • Signature line • Some states require NPI number on all scripts (NJ)

  4. CONTROLLED SUBSTANCE Rx • Doctor name/address/telephone # • Patient name • Address • Added by pharmacist • Patient age • Usually only put if pediatric Rx • Date • Good for six months from date of issue • Drug info area • Refill line • Schedules III and IV allow 5 refills within 6 months of issue • Signature line • DEA number • Some states require DPS (TX) or NPI number as well

  5. Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D.6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333 (281)277-1010 450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815 NAME Joe Johnson AGE ______________ ADDRESS_____________________________________________________DATE 3-3-09 Rx Combigan 10ml 1 gtt bid OU REFILLS--3Jill Autry, O.D.

  6. Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D.6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333 (281)277-1010 450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815 NAME Joe Johnson AGE ______________ ADDRESS_____________________________________________________DATE 3-3-09 Rx Keflex 500mg #20 1 po bid until gone REFILLS--0Jill Autry, O.D.

  7. Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D.6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333 (281)277-1010 450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815 NAME Joe Johnson AGE ______________ ADDRESS_____________________________________________________DATE 3-3-09 Rx Doxycycline 50mg #60 1 po bid with food REFILLS--0Jill Autry, O.D.

  8. PRESCRIBING GUIDELINES • Do not have to write “Sig.”… • Do not have to write “po” • Do not have to know if available in capsules vs. tablets • Can put more than one medication on the same Rx pad (except controls) • Write “Brand Name Medically Necessary” when a generic is not desired • Otherwise, generic is mandated

  9. Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D.6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333 (281)277-1010 450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815 NAME Joe Johnson AGE ______________ ADDRESS_____________________________________________________DATE 3-3-09 Rx Pred Forte 1%, 10ml 1 gtt q2h OD-Shake Well Brand Name Medically Necessary REFILLS--zeroJill Autry, O.D.

  10. Edward C. Wade, M.D. Ting Fang-Suarez, M.D.Chris Allee, O.D. Randy Reichle, O.D.Jill Autry, O.D. 6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333 (281)277-1010 -------------------------------------------------------------------------------------------------------------------------- NAME Steven MichaelsAGE ADDRESS_____________________________________________________DATE 05-30-2008 Rx Phenergan 25mg #20 1 po q4-6h prn N & V REFILLS--ZEROJill Autry, O.D.

  11. qd-daily bid-twice daily tid-three times daily qid-four times daily qod-every other day 5X daily 9X daily gtt-drop ung-ointment po-by mouth IV-intravenous IM-intramuscular SQ-subcutaneous ABBREVIATIONS

  12. wc-with food tud-take as directed ud-as directed ac-before meals pc-after meals qhs-every bedtime prn-as needed for UAT-until all taken achs-before meals and at bedtime sx-surgery tx-treatment/therapy NKDA-no known drug allergies N/V-nausea & vomiting ABBREVIATIONS

  13. MEASUREMENTS • mg-milligram • kg-kilogram • 1 kg=2.2 lb • 1cc=1ml • 1 tsp=5 ml • 1 tbsp=15 ml • 1 ml=20 drops

  14. Before you prescribe… • Allergic to anything? • What other meds are they taking? • Rx • OTC • Vitamins/Herbals • What systemic conditions do they have? • Especially note hepatic and renal problems.

  15. Before you prescribe… • Do they need it? • Pregnant? Nursing? Trying? • Age and weight of child? • 12 yo=Adult in most cases • Check drug monograph for dosing • 1 kg=2.2 lbs

  16. PAYING FOR MEDICATIONS • Have prescription insurance? • Consider generic availability for self-pay. • Often in multiple daily dosages • Decreases compliance • Have mail order program? • Chronic medications like glaucoma drops, doxycycline, Restasis® • Must write “Dispense 90 day supply” on Rx • Cheaper and better compliance w/3 mo supply

  17. Edward C. Wade, M.D. Ting Fang-Suarez, M.D.Chris Allee, O.D. Randy Reichle, O.D.Jill Autry, O.D. 6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333 (281)277-1010 -------------------------------------------------------------------------------------------------------------------------- NAME Steven MichaelsAGE ADDRESS_____________________________________________________DATE 05-30-2008 Rx Combigan 5ml 1 gtt bid OU Dispense 90 day supply REFILLS--ZEROJill Autry, O.D.

  18. FOR MEDICAID • Many states get a certain # scripts a month free • Everything else they pay for unless certain conditions/age • End stage renal disease/blindness • Children/pregnancy • Institutionalized/nursing home • Some states brand # capped/unlimited generics • medicaidbenefits.kff.org • Approved meds often change yearly • Prior authorization in place for most states

  19. WHAT IS PRIOR AUTHORIZATION? • Must meet certain requirements before authorizing payment for Rx • Pharmacist receives a rejection statement from insurance company • Tells patient or calls physician regarding prior authorization • Physician must call insurance company to provide information • Insurance company may or may not authorize payment

  20. INDIGENT PROGRAMS • Allergan (Lumigan, Alphagan, Restasis) • 1-800-553-6783 • Alcon (Azopt, Travatan, Betoptic S) • 1-800-222-8103

  21. PRESCRIBING FOR WOMEN • Pregnant/nursing or thinking about it? • Consult OB-GYN if necessary • OK in pregnancy • Augmentin, erythromycin, Zpack, amoxicillin • Tylenol #3, Vicodin • Prednisone (oral and topical) when necessary • Acyclovir and other oral antivirals

  22. PRESCRIBING FOR WOMEN • On birth control pills? • Counsel and document for concomitant antibiotic therapy-controversial if true interaction exists • No doxycycline during pregnancy/breast feeding

  23. PRESCRIBING FOR CHILDREN • Children 12 years old and older can be dosed as adults unless otherwise noted • Look up dosage for child • Given in mg/kg/day • Determine how many kg child weighs • 1 kg=2.2 lbs • Multiply mg and kg to get total DAILY dose • Divide by number of doses per day • Choose closest available dosage strength

  24. PEDIATRIC EXAMPLE • 40 lb, 5 year old with preseptal cellulitis • 1 kg=2.2 lbs. • 40 lb/2.2 = 18 kg • Weight in kg approx. ½ weight in pounds • Doctor chooses Augmentin for antibiotic therapy

  25. AUGMENTIN PEDIATRIC INFO • 20-40 mg/kg/day of amoxicillin in divided doses every 8-12 hours • If patient weighs 88 lb. or more, dose as adult • 125mg and 250mg/5ml suspensions • Dose q8h

  26. DOSAGE CALCULATION • 40mg/kg/day divided q8h • 18 kg x 40mg=727 mg/day • Divide 727 mg by 3 (i.e. q8h) • =242mg q8h

  27. 40 lb. ÷ 2.2 = 18 kg________________________18 kg x 40 mg/kg/day =727 mg/day________________________727 mg/day ÷ 3 = 242 mg q8h________________________Round to 250 mg q8h

  28. HOW SUPPLIED • AUGMENTIN 125 mg/5 mL • 75 mL bottle, 100 mL bottle, 150 mL bottle • AUGMENTIN 200 mg/5 mL • 50 mL bottle, 75 mL bottle, 100 mL bottle • AUGMENTIN 250 mg/5 mL • 75 mL bottle, 100 mL bottle, 150 mL bottle • AUGMENTIN 400 mg/5 mL • 50 mL bottle, 75 mL bottle, 100 mL bottle

  29. READY TO PRESCRIBE • Prescribe 250mg/5ml; 1 tsp q8h • #150ml gives 10 day course

  30. Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D.6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333 (281)277-1010 450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815 NAME Morgan Smith AGE ___5__ ADDRESS_____________________________________________________DATE 3-3-10 Rx Augmentin 250/5 1 tsp q8h x 10 days #150 REFILLS--0Jill Autry, O.D.

  31. ORAL ANTIBIOTICS • Is an oral antibiotic truly needed? • Check allergy information • Use less expensive antibiotics when possible • Consider covering for Haemophilus influenzae in pediatric patients • Less Hflu since Hib vaccine became widespread • Take full course of therapy

  32. OCULAR ANTIBIOTIC USES • Preseptal cellulitis • Dacryocystitis • Dacryoadenitis • Canaliculitis • Chlamydia • Dry eye/posterior blepharitis/ocular rosacea • Posterior toxoplasmosis activation • Endophthalmitis prevention

  33. ALLERGIC REACTIONS • Hypersensitivity reaction mediated by IgE • 5-10% of all adverse drug reactions • Skin rash, hives, or itching • Wheezing or trouble breathing • Swelling of the face, lips, or throat • Nausea, vomiting, diarrhea • Discontinue use immediately; Consult physician • Severe reactions demand emergency care

  34. ORAL ANTIBIOTICS • Controversial whether antibiotics and birth control truly interact-still counsel and document • Can cause thrush, vaginal yeast infections • Take doses with yogurt • Stop antibiotic if patient reports severe diarrhea/blood in stool • Concerns of pseudomembranous colitis

  35. AMOXICILLIN • Penicillin antibiotic (aminopenicillin) • Extended coverage over standard PCN • Good for staph infections because resistant to beta lactamases • Also has some gram negative coverage • Gram negative resistance increasing • Inexpensive

  36. AMOXICILLIN DOSAGE • Skin and soft tissue infections • Adults • 875mg q12h • Children • 20-40mg/kg/day divided q8h

  37. Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D.6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333 (281)277-1010 450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815 NAME Jack Cooper AGE ________ ADDRESS_____________________________________________________DATE 3-3-09 Rx Amoxicillin 875 1 po bid x 10 days #20 REFILLS-- 0Jill Autry, O.D.

  38. AUGMENTIN • Augmentin = Amoxicillin + Clavulanic acid • Cannot use if penicillin allergic • Clavulanic acid is a “suicide inhibitor” • Protects amoxicillin from beta-lactamases • Does not have antibiotic action itself • Allows increased coverage with less destruction by beta-lactamases • Also covers anaerobes • Good for human and animal bites

  39. AUGMENTIN INFO • Can use in pregnancy (category B) • Can use in children • Can cause nausea/vomiting/diarrhea • Take with food/yogurt • Few drug interactions • Allopurinol/probenecid (both for gout) • 875mg bid • Generic available but still expensive ($60.54)

  40. Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D.6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333 (281)277-1010 450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815 NAME Jack Cooper AGE ________ ADDRESS_____________________________________________________DATE 3-3-09 Rx Augmentin 875mg 1 po bid x 10 days #20 REFILLS-- 0Jill Autry, O.D.

  41. CEPHALOSPORINS • Beta-lactam antibiotic class • Increased coverage over penicillin class • 3-10% cross-sensitivity to penicillin class in regards to allergic reactions • Four generations of cephalosporins • Increasing gram negative activity from 1 to 4 • First and second generations better for ocular conditions (more likely gram positive)

  42. CEPHALEXIN • Brand name KEFLEX® • First generation cephalosporin • Good gram positive coverage (Staph/Strep) • Cheap • Adult dose is 500mg bid • Also available in suspension for children • 20-40mg/kg/day divided q8h

  43. Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D.6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333 (281)277-1010 450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815 NAME Jack Cooper AGE ________ ADDRESS_____________________________________________________DATE 3-3-09 Rx Keflex 500mg 1 po bid UAT #20 REFILLS-- 0Jill Autry, O.D.

  44. ALLERGIC TO PENICILLIN? • Small percentage of patients will also be allergic to cephalosporins • Literature suggests anywhere from 3-10% cross-sensitivity • Could use a –mycin, –cycline, -quinolone • Could use Septra if not sulfa allergic

  45. MACROLIDES • Inhibit bacterial protein synthesis • Erythromycin, clarithromycin, azithromycin • Use with caution in liver disease • Drug interactions increased (next slide) • Great for penicillin allergic patients

  46. SELECT MACROLIDE DRUG INTERACTIONS • Theophylline (asthma, COPD) • Dilantin, Tegretol, Depakote (epilepsy) • Digoxin (Congestive heart failure) • Coumadin (anticoagulant) • Zocor, Mevacor, Lipitor (cholesterol) • Norpace (antiarrythmic) • Many antiretroviral (HIV) medications • Ergot derivatives (migraines)

  47. ZITHROMAX(Azithromycin) • Macrolide antibiotic • Dosing regimen increases compliance • OK in pregnancy and children • Less GI effects than erythromycin • Less drug interactions than other macrolides • Drug of choice for chlamydial conjunctivitis

  48. ZITHROMAX • Z-pack • 500mg day one; 250mg days 2-5 • Great for compliance • For milder infections • Treatment of chlamydia with 1 g dose • Prescribe four 250mg tablets • Take all at once

  49. Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D.6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333 (281)277-1010 450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815 NAME Jack Cooper AGE ________ ADDRESS_____________________________________________________DATE 3-3-09 Rx Zpak REFILLS-- 0Jill Autry, O.D.

  50. Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D.6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333 (281)277-1010 450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815 NAME Jack Cooper AGE ________ ADDRESS_____________________________________________________DATE 3-3-09 Rx Zithromax 250mg #4 Take 4 pills all at once REFILLS-- 0Jill Autry, O.D.

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