Update on Oral Medications - Pennsylvania Optometric Association
Update on Oral Medications Carlo J. Pelino, OD, FAAO [email protected] !"#$#%"$&'(")%&*)+,We have no relevant financial relationships to disclose and no proprietary interest in any product discussed in this presentation. Joseph J. Pizzimenti, OD, FAAO [email protected] .*+,)-'/*$& What pharmacotherapy means to optometry 0*'1,*2"3-'+)-4+&'%&"#"%$&'"#4*,5$6"*#'"# 67-'6,-$65-#6'*4'*%+&$,'%*#3"6"*#)'+)"#8 )9)6-5"%'5-3"%$6"*#): The ability to use pharmaceutical agents has enabled optometrists to become true primary health care providers. Principles of Pharmacology ;*+6-)'*4'(,+8'<35"#")6,$6"*#= >'<&"5-#6$,9' >'?+@&"#8+$&' >'A,$&' >';-%6$&' >'B$,-#6-,$& >'?+@%+6$#-*+)'C?.D' >'E#6,$5+)%+&$,'CEFD' >'E#6,$2-#*+)'CEGD > 'A67-, >'E#7$&$6"*# >'0*1"%$& • Pharmacokinetics: What the body does to a drug • Pharmacodynamics: What the drug does to the body • Always keep in mind the contraindications, side effects and drug interactions before starting medication. • Drug risks vs. benefits • Keep in mind the age and weight of the patient • Consider starting with one half in the very young or very old • Elderly may be on multiple meds – may lead to adverse reactions • Allergy history Principles of Pharmacology • Drug Metabolism – Most drugs metabolized by liver enzymes • Drug Excretion – The kidney is the major route • Some drugs are excreted after metabolism • Some drugs are excreted unchanged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ach patient is unique. > 'O$%6-,"*)6$6"%'W')6*1)'67'8,*Q67'_',-1&"%$6"*#'*4'67-'@$%6-,"$ > 'O$%6-,"%"3$&'W'R"&&)'67-'@$%6-,"$ J7"%7'(,+8'6*'U)-'```` >'A,8$#")5a)'E3-#6"69 >'B$6"-#6'%*#)"3-,$6"*#) >'E55+#-')9)6-5'%*#3"6"*# >'b"3#-9'*,'&"2-,'3")-$)>'B,-8#$#6_#+,)"#8 >'<8>'OFE >'?$4-69'*4'67-'3,+8 >'.*)6 FDA Use-in-Pregnancy Ratings A <3-c+$6-d'Q-&&Z%*#6,*&&-3')6+3"-)'"#'1,-8#$#6'Q*5-#'7$2-'#*6' )7*Q#'$#'"#%,-$)-3',")R'*4'4-6$&'$@#*,5$&"6"-)'6*'67-'4-6+)'"#'$#9 6,"5-)6-,'*4'1,-8#$#%9:' B <#"5$&')6+3"-)'7$2-',-2-$&-3'#*'-2"3-#%-'*4'7$,5'6*'67-'4-6+)'A; Q-&&Z%*#6,*&&-3')6+3"-)'"#'1,-8#$#6'Q*5-#'7$2-'4$"&-3'6*'3-5*#)6,$6$',")R'6*'67-'4-6+)'"#'$#9'6,"5-)6-,. 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Types of Pain Nociceptive • Expected result from tissue injury • Normal neural transmission Neuropathic The World Health Organization Pain Ladder Mild Pain Oral NSAID , Non Opioid Analgesic • Primary lesion in the CNS Moderate Oral Opioid • Chronic Severe Parenteral Opioids (Morphine) Intractable Invasive therapy • Localized, resolves 9-%(!Z!L-N3#44#%0'C!O!9-#3.&+($!9.&-%+ A&33!M&4"'#-&!W20+/203(/(:+ W20+/203(/#+&!9[ \2&'&!#'&!%2'&&!4#(-!$#%&.0'(&+!0,!#-#3.&+($+X >'])&'!%2&!A0*-%&' >!80-@-#'$0%($!/'&+$'(/%(0>!8#'$0%($!/'&+$'(/%(0- 9'#$2#:0-($!9$(: P(/00>C.&-#+& P&*<&%'(&-&+ AC$300>C.&-#+& W'0+%#.3#-:(-+ \2'04"0>#-&!9[ ])&'!%2&!A0*-%&'X 8^9L7^ 9+/('(L"*/'0,&- • 9-%(!@!(-N3#44#%0'C • 9-#3.&+($ • 9-%(!Z!/C'&%($ >!L-$'&#+&!"3&&:(-.!%(4& 9$&%#4(-0/2&-!B\C3&-03D!=5!0-3C!#-#3.&+($!#-:!#-%(@/C'&%($!V \C3&-03!B#$&%04(-0/2&-D >!L+!%2&!3&#:&'!(-!]\A!/#(-!$0-%'03 >!_&4&4"&'!(%!2#+!-0!#-%(@(-N3#44#%0'C!/'0/&'%(&+ >!`+&!#%!E[F!4.!&)&'C!a!20*'+ L"*/'0,&-!B!M0%'(-H!9:)(3H!8*/'(-D 'A04&+!(-![RR!4.!"'0U-!%#"3&%+ 9+/('(-!B#$&%C3+#3($C3($!#$(:D >!70!-0%!.()&!%0!$2(3:'&-!#-:!%&&-#.&'+!b!_&C&c+!+C-:'04& >!M#C!$#*+&!KL!"3&&:(-. >!M#C!(-:*$&!#+%24# >!9)0(:!(-!/#%(&-%+!U(%2!-#+#3!/03C/+!Z!(-$'&#+&:!(-$(:&-$&!0,!#33&'.C >!70!-0%!.()&!(,!/#%(&-%!(+!0-!A0*4#:(-H!d&/#'(>!_&-#3!(-+*,N($(&-$C!#-:!A0-.&+%()&!d&#'%!e#(3*'&!Z!$0-%#$%!WAW 8#"*4&%0-&!B_&3#,&-D!Z!8^9L7 !`+&!#%!aRR!4.!SL7 !!"#$%&'()*+,*-..*/0*1!2*3*,&*456()&6*7*8888 e&3:&-&!BW('0>($#4D!Z!8^9L7 >'IR!4.!#-:![R!4. >'e&U&'!KL!+(:&!&,,&$%+ >!e79!/'&.-#-$C!A#%&.0'C!A! >!P&++!/'0"3&4+!U(%2!<(:-&C!,*-$%(0- >!\2&!'&$044&-:&:!:0+&!(+![R!4.!:#(3C!#+!#!+(-.3&!:0+&5! >!`+&:!,0'!%2&!4#-#.&4&-%!0,!4(3:!%0!40:&'#%&!/#(-H!,&)&'H!#-:!(-N3#44#%(0-5 >!\2&!e79!#//'0)&:!-#"*4&%0-&!(-!7&$&4"&'!IffI >!egP7g8g?!(+!$0-%'#(-:($#%&:!,0'!%2&!%'&#%4&-%!0,!/&'(@0/&'#%()&!/#(-!(!!!%2&!+&%%(-.!0,!$0'0-#'C!#'%&'C!"C/#++!.'#,%!BA96KD!+*'.&'C! >!egP7g8gH!3(<&!0%2&'!8^9L7+H!$#-!$#*+&!KL!:(+$04,0'%!'#'&3CH! !!!+&'(0*+!KL!+(:&!&,,&$%+!+*$2!#+!*3$&'+!#-:!"3&&:(-. >!FRR!#-:!JFR!4.!@!0-$&!:#(3C!:0+(-. >!\2&!'&$044&-:&:!+%#'%(-.!:0+&!(+!IRRR!4.!:#(3C!#+!#!+(-.3&!:0+&5 >!P(<&!0%2&'!8^9L7+H!-#"*4&%0-&!(+!.&-&'#33C!#)0(:&:!:*'(-.!/'&.-#-$C !!"&$#*+&!(%!4#C!#,,&$%!%2&!$#':(0)#+$*3#'!+C+%&4!0,!%2&!,&%*+5 >!egP7g8g!(+!(-:($#%&:X >!e0'!'&3(&,!0,!%2&!+(.-+!#-:!+C4/%04+!0,!0+%&0#'%2'(%(+5 >!e0'!'&3(&,!0,!%2&!+(.-+!#-:!+C4/%04+!0,!'2&*4#%0(:!#'%2'(%(+ >!W'&+$'(/%(0-!(+!-&&:&: K&-&'($!8#4&! 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Large corneal abrasion d&'/&%($!P&+(0- 8#'$0%($!W'&+$'(/%(0- • Pain • Temperature • Light (crude) touch Projects to a specific area of 3, 1, 2 of cerebral cortex • M*+%!2#)&!7g9!k!%0!/'&+$'("& >!]/(0(:!#-#3.&+($ >!9'&!$2&4($#3!$04/0*-:+!%2#%!2#)&!40'/2(-&@3(<&!#$%(0-+ >!l8#'$0%($m!Z!'&,&'+!%0!$2&4($#3!#.&-%+!%2#%!(-:*$&!+3&&/O+%*/0' >!7'*.!0,!N('+%!$20($&!,0'!+&)&'&H!#$*%&!/#(• ;0'<!"C!#,,&$%(-.!"0%2!%2&!:*'#%(0-!#-:!&40%(0-#3!$04/0-&-% >!\2&'&!#'&!a!$3#++&+!0,!0/(0(:!'&$&/%0'+!(-!%2&!"0:C >!M*H!i#//#H!7&3%#H!^(.4#!0/(0(:!'&$&/%0'+ Spinothalamic Tract Cross over • `-3(<&!%2&!8^9L7+!%2&!0/(0(:+!:0!-0%!2#)&!#!l$&(3(-.m!&,,&$% >!M#C!*+&!U(%2!+&)&'&!$2&4($#3!%'#*4#H!+$3&'(%(+H!"3*-%!%'#*4# 8#'$0%($!W'&+$'(/%(0• \2&!A0-%'033&:!^*"+%#-$&!9$%!0,!IfJR!'&.*3#%&+!%2&!*+&!0,!#33! !!:'*.+!%2#%!#$%!0-!%2&!A8^!#-:!2#)&!%2&!/0%&-%(#3!,0'!#"*+& F!+$2&:*3&+!0,!:'*.+!*-:&'!%2&!7g9 ^$2&:*3&!I!X!-0!#//'0)&:!0'!#$$&/%#"3&!4&:($#3!*+&!(-!%2&!`-(%&:!^%#%&+ !!!!!!!!!!!!!!!!!!!!B!d&'0(-H!4#'(n*#-#VH!P^7!D ^$2&:*3&![!X!;'(%%&-!_>!U(%2!-0!'&N(33+ !!!!!!!!!!!!!!!!!!!!Bd(.2!/0%&-%(#3!,0'!#"*+&!Z!0>C$0:0-&H!$0$#(-&H!4&%2#:0-&H!40'/2(-&!D ^$2&:*3&!E!#-:!aX!h&'"#3!0'!U'(%%&-!_>!U(%2!*/!%0!F!'&N(33+!,0'!j!40-%2+ !!!!!!!!!!!!!!!!!!!!!!!!!!!!!BP0U&'!/0%&-%(#3!,0'!#"*+&!Z!$0:&(-&H!2C:'0$0:0-&H!/'0/0>C/2&-&D >!\2&!A0-%'033&:!^*"+%#-$&!9$%!0,!IfJR!(+!'&.*3#%&:!"C!%2& !!!7'*.!g-,0'$&4&-%!9:4(-(+%'#%(0- M(3:!%0!M0:&'#%&!W#(>!\C3&-03!E \C3&-03!BERR!4.D!o!A0:&(-& M0:&'#%&!%0!^&)&'&!W#(>!P0'%#" \C3&-03!BFRR!4.D!o!dC:'0$0:0-& >!h($0:(\C3&-03!BFRR!4.D!o!dC:'0$0:0-& ^&)&'&!W#(>!W&'$0$&% \C3&-03!o!]>C$0:0-& • ]-&!%0!%U0!%#"3&%+!W]!&)&'C!a@j!20*'+!#+!-&&:&:!,0'!/#(- • W'&+$'("&!#33!0,!%2&+&!#-#3.&+($+!,0'!-0!40'&!%2#-!%2'&&!:#C+!ppp ^$2&:*3&!F!X!_>!N(33&:!#+!#*%20'(1&:!"C!/'#$%(%(0-&' !!!!!!!!!!!!!!!!!!!!P(4(%&:!#"*+&!/0%&-%(#3!Z!-0-&!(-!%2(+!.'0*/!*+&:!,0'!0$*3#'!#-#3.&+(# !B_0"(%*++(-D What about Codeine ???? Must be metabolized to morphine to have analgesic effect Other metabolites cause nausea and dysphoria 10% of population can not metabolize, so no analgesic effect 2% are ultra rapid metabolizers – prone to morphine intoxication at normal doses Common Opioid Side Effects Nausea and vomiting Constipation Itchiness Respiratory depression Mental confusion Hypersensitivity reactions `3%'#4!Z!!\'#4#:03!dAP!B80-@-#'$0%($D! !!!!!!!A8^!#.&-%!Z!'&:*$&+!%2&!/&'$&/%(0-!0,!/#(>!gQ*#3!(-!&,,&$%()&-&++!#+!\C3&-03!E >!;&#<!0/(0(:!'&$&/%0'!"(-:(-. >!A#-!"&!%#<&-!U(%20*%!'&.#':+!%0!4+ >!M(-(4#3!+(:&!&,,&$%+!B!$0-+%(/#%(0-H!:(11(-&++!#-:!-#*+&#!D >!]-&!FR!4.!%#"3&%!SL7!0'!W_8! -0%!%0!&>$&&:!aRR!4.!O!:#C 8#'$0%($!#.&-%+!$#-!$#*+&X >'63*''&:!)(+(0- >!7'0U+(-&++ >!7(11(-&++ >!\#<&!8#'$0%($!#.&-%+!U(%2!,00:!%0!#)0(:!KL!*/+&% >!93$0203!+20*3:!"&!#)0(:&:!U(%2!/#%(&-%+!%#<(-.!-#'$0%($!#.&-%+ A0-%'#(-:($#%(0-+!0,!8#'$0%($!#.&-%+= >'W'(0'!#::($%(0- >!_&-#3!:C+,*-$%(0>!P()&'!:C+,*-$%(0>!`+&!0,!A8^!#.&-%+!Z!\'($C$3($!#-%(:&/'&++&-%+ >!P*-.!/'0"3&4+!@!A]W7 +O/![!U<+!jR!4.!/0!/'&: ^$3&'(%(+ 80-+%&'0(:#3!#-%(@(-N3#44#%0'C!:'*.+!B!8^9L7D!Z!:(,,*+&!#-: -0:*3#'!+$3&'(%(+ >!L"*/'0,&-!aRR@jRR!4.!W]!SL7!,0'!#%!3&#+%![!U&&<+ >!L-:04&%2#$(-![F!4.!SL7!>!E@a!U<+ +O/![!40'&!U<+!0-!/0!/'&: e&#%*'& g/(+$3&'(%(+ ^$3&'(%(+ g+5@-,'*4'1$6"-#6) [^ j^ <8- NK KM !^C+%&4($!^%&'0(:+ >!W'&:-(+0-&!jR@qR!4.!W]!O!:#C!,0'!a!U<+!%2&-!+30U %#/&' /-#3-, [LS ^LS ]jS ^MS !L44*-0+*//'&++()&!%2&'#/C >!0'#3!AC$30/20+/2#4(:&!Z!40+%!,'&Q*&-%3C!*+&: >!0'#3!M&%20%'&>#%& ;$%- Q7"6-'\NS Q7"6-'^jS O"&$6-,$& NjS KMS ?9)6-5"%'3")-$)- ;<' M\S';< !^*"$0-n*-$%()#3!+%&'0(:+!#'&!$0-%'#(-:($#%&:!(-!+$3&'(%(+ !\0/($#3!+%&'0(:+!#'&!'#'&3C!(-:($#%&:!(-!+$3&'(%(+!#-:!#'&!-0%!&,,&$%()& 5-# Q*5-# g/(+$3&'(%(+!#-:!^$3&'(%(+X!A3(-($#3!e&#%*'&+!#-:!\'&#%4&-%!_&+*3%+5!70*.!Y#"+H!&%!#35 ]/2%2#34030.C![RRRr!IERXajf@aJj. d*4#-!d&'/&+)('*+!L-,&$%(0-+X >!d*4#-!d&'/&+!h('*+!Z!\C/&!I Questions and Comments? >!d*4#-!d&'/&+!h('*+!Z!\C/&![ >!h#'($&33#!10+%&'!)('*+!Z!ddh!E >!g/+%&(-@6#''!)('*+!Z!ddh!a >!AC%04&.#30)('*+!Z!ddh!F >!ddh!jH!JH!q d^h!(+!%2&!3&#:(-.!$#*+&!0,!"3(-:-&++!(-!%2&!:&)&30/&:!U0'3: L-$(:&-$&!0,!ds]!(-!%2&!/0/*3#%(0-!tJF!C&#'+!03:!(+!#"0*% FR!/&'!IRRHRRR M&#-!#.&X d^h!X!a%2!:&$#:& ds]!X!J%2!:&$#:& W'&)&-%(0-!0,!d&'/&+!s0+%&'!Z!h#$$(-&!'&$044&-:&:!,0'!#33! /&0/3&!0)&'!jR5!^(-.3&!+20%5!8&&:!%0!"&!0,,!#$C$30)('![a!20*'+ /'&!)#$$(-&!#-:!Ia!:#C+!/0+%!)#$$(-&!"&$#*+&!0,!3()&!)('*+5 A#-!-0%!"&!(44*-0$04/'04(+&:!B9L7^H!3C4/204#H!&%$5D ]$*3#'!$04/3($#%(0-+!(-!ds] • `)&(%(+X!%2&!40+%!,'&Q*&-%!N(-:(-. !!(-:($#%(-.!0$*3#'!(-)03)&4&-% >!9,,&$%+!fRG!0,!/#%(&-%+!U(%2 !!0$*3#'!(-)03)&4&-% >!g'*/%()&!3&+(0-+!#-:!:(3#%&:!('(+!)&++&3+ !!4#C!3&#:!%0!+&$%0'#3!('(+!#%'0/2C >!M#C!.&%!2C/0/C0-H!2C/2&4#H!0'!#-%5!#-: !!/0+%5!+C-&$2(# >!M#C!&)03)&!%0!#-%5!+&.5!(+$2&4(#!0'!/2%2(+(+ >!M#C!2#)&!#!$2'0-($!0'!'&3#/+(-.!<&'#%0*)&(%(+ ]'#3!9-%()('#3!M&:($#%(0-+ >!L-2("(%+!)('#3!789!+C-%2&+(+!B!M#>(4#33C!&,,&$%()&!U(%2(-!E!:#C+!D >!g-1C4&!l%2C4(:(-&!<(-#+&m!/'0:*$&:!"C!)('*+!#$%()#%&+!%2& :'*.b+#,&%C >!9$C$30)('!B!s0)('#>D! qRR!4.!BW]D!!!!!F!>!:#C !!J@IR!:#C+ >!e#4$C$30)('!B!e#4)('!D FRR!4.!BW]D!!!!!E!>!:#C !!J!:#C+ >!h#3#$C$30)('!B!h#3%'&>!D IRRR!4.!BW]D!!!E!>!:#C !!J!:#C+ L4/0'%#-%!80%&X!M#<&!+*'&!-0!li(:-&Cm!:(+&#+&!Z!$0-%#$%!WAW!0'!-&/2'030.(+% K00:!#%!'&:*$(-.!/#(-!U(%2!s0+%&'5 e#4)('!2#+!%2&!40+%!"(0#)#(3#"(3(%C A0440-!9:)&'+&!g,,&$%+X!-#*+&#H )04(%(-.H!d9H!:(11(-&++H!#":04(-#3 /#(-H!,#$(#3!&:&4#Hh(+*#3 2#33*$(-#%(0-+ WHAT’S NEW? • Generic Valtrex, Famvir s0)('#>!B#$C$30)('D To Treat Shingles (VZV), Give Double the Dose Used for HSV Antiviral Drug Dosing for H. Zoster Dosing for HSV > aRR!4.!#-:!qRR!4.!%#"3&%+ Acyclovir Valacyclovir Famciclovir 800mg 5x q.d. x 1wk 1,000mg t.i.d. x 1 wk 500mg t.i.d. x 1 wk 400mg 5x q.d. x 1wk 500mg t.i.d. x 1 wk 250mg t.i.d. x 1 wk > A#-!"&!*+&:!(-!d^h!'&$*''&-%!<&'#%(%(+ > A#%&.0'C!6!Z!/'&.-#-$C!$3#++(N($#%(0- Source: Review of Optometry 2010 Clinical Guide to Ophthalmic Drugs. 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