BVS 611 Slide Deck II

1. BVS 611 Slide Deck II

2. Which of the following insulin products is a short-acting insulin? a.) insulin aspart b.) insulin glargine c.) insulin detemir d.) NPH insulin Which of the following is a potential consequence of diabetes-related gastroparesis? a.) increased risk of myocardial infarction b.) decreased immunocompetence c.) speeding up hepatic metabolism of orally-ingested drugs d.) slowing the absorption of orally-ingested drugs

3. BVS 611 – Pharmacology I 8. Medications for Diabetes Other medications:

4. BVS 611 – Pharmacology I 8. Medications for Diabetes Other medications:

5. BVS 611 – Pharmacology I 8. Medications for Diabetes Other medications:

6. BVS 611 – Pharmacology I 8. Medications for Diabetes Other medications:

7. BVS 611 – Pharmacology I 8. Medications for Diabetes Other medications:

8. BVS 611 – Pharmacology I 8. Medications for Diabetes Other medications:

9. BVS 611 – Pharmacology I 8. Medications for Diabetes Other medications:

10. BVS 611 – Pharmacology I 8. Medications for Diabetes Other medications:

11. BVS 611 – Pharmacology I 8. Medications for Diabetes Other medications:

12. BVS 611 – Pharmacology I 9. Respiratory Medications

13. BVS 611 – Pharmacology I 9. Respiratory Medications

14. BVS 611 – Pharmacology I 9. Respiratory Medications

15. BVS 611 – Pharmacology I 9. Respiratory Medications

16. BVS 611 – Pharmacology I 9. Respiratory Medications

17. BVS 611 – Pharmacology I 10. Anti-infective Medications Introduction to Anti-infectives Microorganisms are living forms of microscopic or submicroscopic size. General groups include: - Bacteria (includes Chlamydiae, Rickettsiae, and Mycoplasma) - Viruses - Fungi - Protozoa Bacteria are single-celled microorganisms occurring in many forms, existing either as free-living organisms, or as parasites (as in the case of obligate intracellular parasites such as Chlamydiae.) Bacteria have a range of biochemical and often pathogenic properties. Bacteria are generally small, with a size ranging from 0.2 to 2 microns. Bacteria are often initially divided into two general groups based on their response to the Gram’s stain procedure: Gram PositiveGram Negative After the cell sample is fixed, stained, and washed, the bacterial cell walls retain the crystal violet dye, or remain stained. These bacteria have a purple cell wall when viewed under the microscope. After the cell sample is fixed, stained, and washed, the bacterial cell walls do notretain the crystal violet dye. (They retain the reddish safranin dye.) These bacteria are decolorized, and have a light reddish cell wall when viewed under the microscope.

18. BVS 611 – Pharmacology I 10. Anti-infective Medications Bacteria are not always able to be fully identified by Gram’s stain alone. Other special stains and dyes may be needed to give a preliminary or final identification of the bacteria: - Acid fast staining (used for Mycobacteria) is one example. Some bacteria are not able to be identified by use of the Gram’s stain since they do not possess a rigid cell wall. Such bacteria may be identified on the basis of rising antibody titers, special immunofluorescence assays, etc. - Legionella (i.e. Legionella pneumophilia) - Rickettsiae (i.e. Rickettsia rickettsiae) - Chlamydia (i.e. Chlamydia pneumonia, C. trachomatis, C. psittaci) - Mycoplasma (i.e. Mycoplasma pneumoniae) The principal groups of true bacteria are distinguished by their morphologic shapes when viewed under a microscope: - Cocci: Spherical. Examples are Streptococci, Staphylococci, and Neisseria - Bacilli: Rod-shaped. Examples are E. coli, Bacillus, and Clostridia - Spirillum: Short, rigid spirals. An example is Vibrio - Spirochetes: Protozoa-like bacteria that are thin, flexible, motile, and spiral-shaped. Examples are Borrelia and Treponema - Fungus-like: Bacteria that possess branching filamentous elements resembling fungal hyphae. Examples are Mycobacteria, Nocardia, and Actinomyces

19. BVS 611 – Pharmacology I 10. Anti-infective Medications - Rickettsiae: Extremely small parasitic bacteria once thought to be viruses because their growth takes place within a host cell. Rickettsiae do possess a cell wall and other bacterial elements. Examples are Coxiella, Typhus and Rickettsia. Not routinely seen on Gram’s stain. - Mycoplasma: Very small bacteria that lack a rigid cell wall. Mycoplasma bacteria are bound by unit membranes, so are not seen on routine Gram’s stain. They are usually diagnosed on the basis of rising antibody titers. An example is Mycoplasma pneumoniae. - Chlamydia: Smaller than Rickettsiae, these bacteria were also once thought to be viruses. Chlamydia are obligate intracellular parasites which do possess cell walls and ribosomes, but must rely on the intracellular processes of the host cell to produce metabolic energy. Not routinely seen on Gram’s stain, Chlamydia are often diagnosed using titers. Examples are Chlamydia pneumoniae, C. trachomatis, and C. psittaci. - Viruses are the smallest microorganisms known to have pathogenic properties in humans. The size of these microorganisms can be in nanomicrons. Viruses commonly consist of a nucleic acid fragment (DNA or RNA) core, a capsid, and a lipoprotein coat. Viruses generally use the structures and systems in host cells to replicate themselves. Viruses most often involved in causing eye infections include the herpes viruses, and adenoviruses.

20. BVS 611 – Pharmacology I 10. Anti-infective Medications Terminology Review Along with initial patient assessment, identification of the pathogen(s) is critical in determining the most appropriate therapy for bacterial infection. Visual appearance/characteristics and laboratory analysis of specimens are very important. SPECIMEN COLLECTION: Specimens should be collected with care to prevent inadvertent contamination. Specimen collection sites should represent the suspected location of infection. Specimen amount should be of sufficient size and numbers. Specimens need to be placed in appropriate containers, and labeled carefully. Delivery to the Laboratory should occur promptly. CULTURE AND SENSITIVITY: A test in which patient specimens are cultured on appropriate media and incubated. Bacteria which have grown on the media are directly isolated, identified, and tested for susceptibility to different antibiotics. Sensitivity testing may be done by using the disc method, automated disc method, or by serial dilution method.

21. BVS 611 – Pharmacology I 10. Anti-infective Medications CULTURES: An example: A Gram’s stain reveals Gram + cocci in chains and pairs. On culturing the bacteria on a blood agar plate, the following may be seen: Colonies surrounded by greenish zones = partially hemolytic bacteria = Alpha hemolytic Streptococcisuch as S. viridans, or S. pneumoniae Colonies surrounded by clear zones = fully hemolytic bacteria = Beta hemolytic Streptococcisuch as Group A Streptococci Colonies not surrounded by zones = non- hemolytic bacteria = Gammahemolytic Streptococcisuch as Enterococci.

22. BVS 611 – Pharmacology I 10. Anti-infective Medications SENSITIVITY: An example: Disc sensitivity testing: Discs containing different antibiotics and/or different concentrations of antibiotics are placed on a growth medium that has been colonized with the cultured bacteria. After incubation, areas of inhibited bacterial colony growth are assessed. Wide zones of inhibited (no) growth indicate antibiotic sensitivity. Areas with minimal growth inhibition indicate minimal antibiotic sensitivity. Areas of no growth inhibition indicate antibiotic resistance. Other methods of assessing antimicrobial resistance and sensitivity include serial dilution testing. SENSITIVE MINIMALLY RESISTANT SENSITIVE

23. BVS 611 – Pharmacology I 10. Anti-infective Medications MINIMUM INHIBITORY CONCENTRATION (MIC): The lowest in-vitro concentration of antibiotic in solution with a bacterial suspension that prevents/inhibits growth of the bacteria after an incubation period. - If the concentration of antibiotic represented by the MIC can be achieved in the patient’s serum by normal routes of delivery, the bacteria is said the be sensitiveto the antibiotic. - If the MIC is above the achievable level, or is within a range that would be toxic to a patient, then the bacteria is said to be resistant to the antibiotic. Susceptibility and resistance are functions of the site of infection, the bacteria, and the antibiotic being tested. BROAD SPECTRUM: Antibiotics which halt the growth of, or eradicate many different bacteria. NARROW SPECTRUM: Antibiotics which are effective for very specific bacteria only.

24. BVS 611 – Pharmacology I 10. Anti-infective Medications BACTERIOCIDAL: Antibiotics whose mechanisms of action usually result in bacterial cell death. BACTERIOSTATIC: Antibiotics whose mechanism of action usually result in inhibiting or arresting the growth, development, or multiplication of the infecting bacteria. VIRUSTATIC (Virucidal): Not commonly used terms. “Anti-viral” is the more common term, since causing outright pharmacologic eradication of the infecting virus is sometimes not possible. Anti-infective Mechanisms of Action Most anti-infectives work by one or more of the following mechanisms: 1. Inhibition of cell wall synthesis, cause cell wall lysis (Penicillins, cephalosporins, vancomycin, (daptomycin)) 2. Alteration of cell membrane permeability, inhibition of active transport across the cell membrane (Most antifungals) 3. Inhibition of protein synthesis via inhibition of ribosomal subunit transcription/translation (Macrolides/ketolides, tetracyclines, glycylcyclines, (daptomycin), quinu/dalfo, aminoglycosides, clindamycin, linezolid) 4. Inhibition of nucleic acid synthesis/replication, stimulating reduction products (Sulfonamides, metronidazole, possibly tinidazole) 5. Inhibition of DNA-gyrase or DNA-polymerase (Fluoroquinolones) 6. Binding to DNA, interfering with/preventing replication (Most antiviral agents)

25. BVS 611 – Pharmacology I 10. Anti-infective Medications • Considerations in Selecting Appropriate Antimicrobial Agents • 1. The infecting microorgansim and its susceptibilities • 2. The type of infection: abscess, UTI, sepsis, meningitis, cellulitis, etc. • 3. Host factors: age, current illnesses, immune status, renal function, allergies, other medications, WBC count, etc.) • 4. Anti-infectives and their properties: dose, routes of administration, metabolic properties, where the drug is excreted, protein binding, tissue penetration capabilities, potential toxicities, potential drug interactions, therapeutic serum concentration levels, etc. • 5. Public health considerations: hospital and community resistance patterns.

26. BVS 611 – Pharmacology I 10. Anti-infective Medications Reminder • Antibiotics are primarily effective against bacteria. They do not have clinical effect against viruses. • Antibiotics are also not effective at treating fungal infections. Antifungal medications are needed to treat these infections. • Some antibiotics also have anti-protozoal properties and can be used to treat infections caused by some protozoa. • Final identification and susceptibilities of the bacteria to anti-infective agents come from culture and sensitivity testing. • Viral infections are commonly diagnosed empirically, but special tests such as immunofluorescent assays or serum titer analysis may be used in some cases of serious or systemic illness. • Most Common Infections of the Eye • Blepharitis • Hordeolum • Conjunctivitis (Bacterial and Viral) • Keratitis (Bacterial and Viral) • Dacryocystitis • Canaliculitis • Endophthalmitis • Retinitis • Orbital cellulitis

30. BVS 611 – Pharmacology I 10. Anti-infective Medications Matching infection with the etiology

31. BVS 611 – Pharmacology I 10. Anti-infective Medications Matching infection with the etiology

32. BVS 611 – Pharmacology I 10. Anti-infective Medications Penicillins MOA: Bacteriocidal: inhibit bacterial cell wall synthesis, inhibit bacterial enzymes which assemble peptidoglycan, activate autolysis. Uses: - Dicloxacillin: Effective against some streptococci and staphylococci. Many bacteria have acquired resistance, limiting its usefulness. Does not work against Pseudomonas. MSSA may respond. MRSA does NOT. Is available in oral form only. - Amoxicillin: Effective against some streptococci, staphylococci, and Listeria. Additional effectiveness against a few gram-negative rods and cocci. Many bacteria have acquired resistance. Is available in oral form only. Does not work against Pseudomonas, MSSA or MRSA. - Amoxicillin/clavulanate: Clavulanate added to restore effectiveness of amoxicillin against some bacteria that have acquired resistance. Used orally for some streptococci and staphylococci, some gram-negative rods and cocci. Does not work against Pseudomonas. MSSA may respond. MRSA does NOT. - Ampicillin: Effective against some streptococci, staphylococci and Listeria. Does not work against Pseudomonas, MSSA or MRSA.

33. BVS 611 – Pharmacology I 10. Anti-infective Medications Penicillins Adverse Effects and Other Information: Amoxicillin and amoxicillin/clavulanate need to be dose- adjusted in patients with renal impairment. Dicloxacillin may not. Consult a pharmacist for assistance on renal dose adjustments if patient reports kidney problems, renal disease, or renal dialysis on the medical history. Follow scope of practice recommendations for duration of therapy and for referral. Consult a pharmacist or a drug information center for additional assistance with recommendations for duration of therapy. Caution in patients with history of allergy to penicillins. Take thorough medication histories. Allergic reactions are a common side effect; can be immediate or delayed and can range from rashes to anaphylaxis. Monitor patients closely. GI effects with oral use have included nausea, vomiting, and diarrhea. CNS effects are rare, but can include confusion, seizures and encephalopathy. (More common in high doses, and in infants/children.) Blood dyscrasias can occur: eosinophilia, thrombocytopenia, rarely leukopenia, neutropenia.

34. BVS 611 – Pharmacology I 10. Anti-infective Medications Cephalosporins MOA: Bacteriocidal: inhibit bacterial cell wall synthesis, inhibit bacterial enzymes which assemble peptidoglycan. Uses: - Cephalexin and Cefadroxil: Effective against many Gram positive bacteria, not good for Gram negative bacteria in general. Will not cover anaerobic bacteria, Pseudomonas, or Enterococci. Many bacteria have acquired resistance to these agents. Available in oral form only. - Cefaclor: Generally the same Gram positive coverage as cephalexin and cefadroxil, has a little more Gram- negative rod coverage. Does not cover enterococci or Pseudomonas. Available in oral formonly. Note: Cefotetan has been re-approved in generic form in the United States. Avoid using or prescribing this cephalosporin in patients taking anticoagulants/blood thinners due to increased risk of bleeding interactions. Adverse Effects and Other Information: Some cephalosporins may need to be dose adjusted in patients who have renal impairment. Consult a pharmacist for assistance on renal dose adjustments if patients report kidney problems, renal disease or renal dialysis on medical history. Other adverse effects include fatigue, dizziness, vertigo, and headache. Rash and other manifestations of allergic responses are common. Exfoliative dermatitis can rarely occur. Nausea, vomiting and diarrhea are common. Hepatic and renal effects may rarely occur. Blood dyscrasias include eosinophilia, thrombocytopenia, neutropenia, and leukopenia can occur.

35. BVS 611 – Pharmacology I 10. Anti-infective Medications Follow scope of practice recommendations for duration of therapy and for referral. Consult a pharmacist or drug information center for additional assistance with recommendations for duration of therapy. It is estimated that 2-10% of patients who are allergic to penicillin will also be allergic to cephalosporins. Allergies to cephalosporins may occur in up to 5% of patients. Reactions may range from rash to anaphylaxis. Take careful patient histories.

36. BVS 611 – Pharmacology I 10. Anti-infective Medications Fluoroquinolones MOA: Inhibition of bacterial DNA-gyrase, which interferes with bacterial reproduction. Effects are often bacteriocidal. Most are broad spectrum. Indications: Some Gram +, many Gram - bacteria. Not good against MRSA, not generally recommended against Enterococci. Most do not adequately cover against Bacteroides, most will cover Chlamydia. Guard against over-use as bacterial resistances are increasing! Uses: Examples: ciprofloxacin, gatifloxacin, levofloxacin, moxifloxacin, norfloxacin, and ofloxacin. Most ophthalmic solutions used in bacterial conjunctivitis will be used for 7 days. Most solutions used in corneal ulcers/keratitis will be used for 5 – 14 days. Newest addition to the group is besifloxacin (Besivance®). Adverse Effects and Other Information: Patients who are allergic to one fluoroquinolone can easily cross-react with others. Avoid use in patients with a history of allergy to any fluoroquinolone. Avoid over-use of fluoroquinolones for conjunctivitis. May cause white precipitate of active drug at the site of epithelial defect that may be confused with a worsening infection. There are numerous potential drug interactions, adverse effects, and cautions with oral use of fluoroquinolones. In addition, renal dose adjustments are also needed in patients with renal impairment or renal disease who take oral dosage forms. (Not generally needed for ophthalmic forms.) Ophthalmic forms will be preferred for treatment in most cases.

37. BVS 611 – Pharmacology I 10. Anti-infective Medications Fluoroquinolones Cautions (for ophthalmic preparations): - Use with great caution if at all in patients with seizure history. - Can increase photosensitivity and cause photophobia. - Counsel patients on potential ophthalmic adverse effects: burning/stinging sensation in the eye, blurred vision, redness/irritation in the eye, eye pain, foreign body sensation, tearing, and/or dry eye. - Rare but potentially serious side effects can include severe exfoliative dermatitis, severe allergic reactions including anaphylaxis, periocular or facial edema, dizziness, etc. - Potential caution in patients taking blood-thinning medications. Oral fluoroquinolones may interact with many other oral medications. Check for potential drug to drug interactions with oral medications before prescribing oral quinolones. Sulfonamides MOA: Sulfa antibiotics are structural analogs of PABA and competitively inhibit the bacterial enzyme necessary for incorporating PABA into dihydrofolic acid, the folic acid precursor. Inhibiting folic acid formation results in the bacteria not being able to synthesize amino acids and DNA. Uses: Originally broad spectrum bacteriostatic antibiotics with specific antibacterial and antiprotozoal activities. Acquired bacterial resistances have limited use of this class, although for some uses, this class of drugs is still somewhat medically important. SMX/TMP is currently one of the oral initial agents to consider for CA-MRSA. ODs can prescribe oral SMX/TMP.

38. BVS 611 – Pharmacology I 10. Anti-infective Medications Sulfonamides Sulfacetamide sodium ophthalmic solution (10%, 15%, 30%), and 10% ophthalmic ointment occasionally used for bacterial conjunctivitis. Other agents used primarily for trachoma /chlamydial infections currently. Topical form not a good option for CA-MRSA. Sulfisoxazole 4% ophthalmic ointment and 4% ophthalmic solution occasionally used for bacterial conjunctivitis. Other agents used primarily for trachoma/chlamydial infections currently.Topical form not a good option for CA-MRSA. Adverse Effects and Other Information: Can cause stinging and burning on application. Allergic reactions are possible. Potential for cross-reactivity with other sulfa-containing drugs. Dermatologic reactions can range from swelling to hives and rash. Severe exfoliative dermatitis is potentially possible. Products are incompatible with silver-containing preparations. Polymyxin and Bacitracin MOA: Polymyxin is a bactericidal agent that works by binding to cytoplasmic membranes, disrupting the structure and altering membrane permeability. Most effects are against sensitive Gram-negative bacteria. (Polymyxin has no effect against MRSA.)Bacitracin is a bactericidal agent that works by binding to bacterial cell membranes and interfering with cell wall synthesis. Most effects are against sensitive Gram-positive bacteria. Uses: Both medications have been used singly, and in combination with other anti-infectives (i.e. neomycin) for short-term treatment of external ocular infections caused by susceptible bacteria. Not for long-term treatment. Acquired bacterial resistance has impacted former widespread usage.

39. BVS 611 – Pharmacology I 10. Anti-infective Medications Polymyxin and Bacitracin Adverse Effects and Other Information: Local adverse effects are possible. Check previous patient sensitivity reactions before usage. Tetracyclines MOA: Inhibit bacterial protein synthesis by binding to the 30-S ribosomal subunit. Bacteriostatic effects, variable effects against some Gram-positive bacteria, reliable effects against systemic Listeria infections. Have effects against some specific Gram- negative bacteria including Neisseria meningitidis and Legionella. Are effective against Mycoplasma, Chlamydia, and Rickettsia. Some anti-clostridial activity, though not against C. difficile. Ophthalmic preparations are no longer available in the U.S. Uses: Oral use should be rare, and considered for very specific conditions only (chlamydial inclusion conjunctivitis, trachoma). The oral tetracycline group includes doxycycline and tetracycline. Adverse Effects and Other Information: There are many potential adverse effects and drug interactions possible with use of tetracycline antibiotics. Doctors of Optometry should prescribe these medications sparingly and with caution.

40. BVS 611 – Pharmacology I 10. Anti-infective Medications • Tetracyclines • Numerous drug-to-drug and drug-to-food interactions exist. Pharmacists can assist in identifying possible interactions • Photosensitivity is common with these antibiotics. • GI effects: antibiotic-associated pseudomembranous colitis, N/V, abdominal pain, potential pancreatitis, hepatic effects • Allergic reactions are possible. Cross-sensitivity exists between agents in the same class. • Avoid use in pregnancy and in children. • Should very rarely be considered in Optometry practice.

41. BVS 611 – Pharmacology I 10. Anti-infective Medications Macrolides MOA: Inhibit protein synthesis by binding to 50-S ribosomal subunit. Activity against some Gram- positive bacteria (Group A, B, C, and G Streptococcus, Streptococcus pneumoniae, MSSA, and Listeria) although resistance to many of these bacteria is increasingly a problem. Some activity against specific Gram-negative bacteria (N. meningitidis, M.catarrhalis, H. influenzae, Legionella) Generally very good for Mycoplasma, Chlamydia, Rickettsia and some Clostridia (though not C. difficile.) Uses: Current California Optometry regulations specify azithromycin is limited to the treatment of eyelid infections and chlamydial disease manifesting in the eyes. Erythromycin 0.5% ophthalmic ointment is still available for superficial ocular infections and neonatal conjunctivitis. Oral clarithromycin and erythromycin should be dose-adjusted in renal impairment. Azithromycin does not need to be dose-adjusted in renal impairment patients. Contact a pharmacist for assistance with dose adjustments, or refer patient. Adverse Effects and Other Information: Taken orally or parenterally, these drugs can cause some potentially serious side effects: - Hepatic complications such as hepatitis and jaundice - Renal complications - GI effects can include GI irritation, nausea, vomiting, and diarrhea - Ototoxicity may occur - Allergic reactions. Cross-reactivity between agents in this class is possible. - Allergic reactions can range from mild rash to anaphylaxis. Numerous potential drug-to-drug interactions exist with erythromycin, clarithromycin and azithromycin. Check with a pharmacist as needed.Caution in patients taking blood-thinning medications. Monitor for the appearance of super-infection (candidiasis).

42. BVS 611 – Pharmacology I 10. Anti-infective Medications Aminoglycosides MOA: Inhibition of bacterial protein synthesis by binding principally to 30-S and 50-S ribosomal subunits. Aminoglycoside action in bacteria is specifically bacteriocidal, however since these drugs do cause eventual cell death through cytoplasmic membrane disruption. Some limited activity against MSSA, but not generally used against Gram-positive bacteria. Used widely for many Gram–negative bacteria. Little to no activity against atypical bacteria, no anaerobic effects. Uses: Ophthalmic products include: gentamicin 0.3% ointment and solution, tobramycin 0.3% ointment and solution, and neomycin (in combination with other anti-infectives such as polymyxin, bacitracin, etc. Occasionally used prophylactically, still used in some bacterial conjunctivitis or keratitis cases. Some concern for recently reported bacterial resistances (Streptococcus pneumoniae, Pseudomonas). Patients who do not respond quickly need rapid referral. Adverse Effects and Other Information: Local irritation can occur with ophthalmic use. Caution in patients with myasthenia gravis as slight potential for neuromuscular junction blockade effects can worsen or exacerbate symptoms. Monitor for appearance of allergic reactions, swelling of eyelids, face, appearance of rash, etc. Dermatologic reactions are rare but possible.

43. BVS 611 – Pharmacology I 10. Anti-infective Medications • Antiviral Agents • Trifluridine 1% ophthalmic solution is indicated for use in Herpes simplex-related keratitis and keratoconjunctivitis. It works by incorporating in place of thymidine into viral DNA, weakening the viral ability to infect tissue. It is not indicated for prophylactic use. Trifluridine 1% ophthalmic solution should be kept refrigerated. Can cause hyperemia, epithelial keratopathy, increased intraocular pressure, dry eye, and irritation. Patients should also be warned that it can cause burning or stinging on instillation. • Vidarabine 3% ophthalmic ointment is indicated for use in Herpes simplex-related keratitis and keratoconjunctivitis. It works by inhibiting viral DNA polymerase and prevents lengthening or building of DNA viral chains. It is not indicated for use in treating infections caused by adenoviruses. Can cause local hypersensitivity reactions including itching, redness, foreign body feeling in the eye, swelling, pain, burning or other irritation on application. It can also increase flow of tears. Can cause increased sensitivity of eyes to light. Recommend sunglasses and avoiding prolonged exposure to sunlight. Can be administered with antibiotics and corticosteroids. Can cause small punctate defects in the cornea with too-frequent use.

44. BVS 611 – Pharmacology I 10. Anti-infective Medications Antiviral Agents Oral acyclovir is listed in the California Optometry scope of practice for treatment of ophthalmic Herpes zoster. Acyclovir works by inhibiting DNA replication and synthesis. Oral acyclovir should not be taken by patients who are sensitive to valacyclovir. Cross-sensitivity can occur. Acyclovir can cause renal failure, and can complicate or worsen renal function in patients with renal impairment. Dose adjustments need to be made in renal failure patients. Consult a pharmacist for assistance, or refer patient. Encephalopathy/neurotoxicity, blood dyscrasias, coagulation problems, hepatic complications, severe skin reactions, visual changes, GI disturbances, agitation, dizziness, myalgia, paresthesias, and other side effects are possible. The drug must be used with caution and close patient monitoring. Oral doses should be taken with a full glass of water. Some potentially serious drug–to-drug interactions are possible. Consult with a pharmacist as needed. Valacyclovir (Valtrex) is a prodrug for acyclovir. MOA is the same as acyclovir. Similar warnings and potential adverse reactions. Valacyclovir has recently been added to scope of practice for doctors of optometry in many states.

45. BVS 611 – Pharmacology I 10. Anti-infective Medications Antiviral Agents Note: Corticosteroids can accelerate the spread of viral infections and are usually contraindicated in superficial Herpes simplex virus keratitis. Steroids may be used concurrently with trifluridine in the treatment of Herpes simplex stromal infections. In these cases, trifluridine should be continued for a few days after the steroid has been discontinued. Combination Products Corticosteroid and anti-infective combinations are sometimes prescribed for steroid-responsive inflammatory conditions with bacterial infections or risk of bacterial infections. Anti-infective component may consist of sulfacetamide sodium, neomycin/polymyxin, gentamicin, or tobramycin. Corticosteroid component may consist of prednisone, hydrocortisone, dexamethasone, or prednisolone. All combination ophthalmic solutions should be shaken well prior to use. Steroid-containing products can increase intraocular pressure. Select for use, and monitor patients appropriately.

46. BVS 611 – Pharmacology I 10. Anti-infective Medications • TYPICAL ADULT ORAL ANTI-INFECTIVE DOSES • Note: • Anti-infective use and dosage should be adjusted as needed on an individual patient basis, taking into account indication for use, allergy /intolerance status, age, height/weight, functional status of metabolic and elimination systems (as appropriate), • C & S results, duration of therapy, potential for drug:drug interactions and adverse effects. • 2. Consult a drug information resource, a pharmacist, and/or a drug information center as needed. Always consult a drug information center or pediatrician for pediatric and infant doses, and the physician supervising the pregnancy of expectant women. • 3. Trade names listed below reflect ORAL dosage forms/products, not ophthalmic products. The symbol ۩indicates a medication where the knowledge of generic name, dose, and comments will be evaluated in BVS 611.

47. BVS 611 – Pharmacology I 10. Anti-infective Medications TYPICAL ADULT ORAL ANTI-INFECTIVE DOSES

48. BVS 611 – Pharmacology I 10. Anti-infective Medications TYPICAL ADULT ORAL ANTI-INFECTIVE DOSES

49. BVS 611 – Pharmacology I 10. Anti-infective Medications TYPICAL ADULT ORAL ANTI-INFECTIVE DOSES

50. BVS 611 – Pharmacology I 10. Anti-infective Medications TYPICAL ADULT ORAL ANTI-INFECTIVE DOSES