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When to use topical NSAIDS after cataract surgery
We’ve been battling the “forces of evil” when it comes to the prescription of topical NSAIDs and cataract surgery. Insurance companies and public-private mixes not only routinely demand generic prescriptions, but pharmacies quite often only stock the lowest priced among these generics.
As a dry eye doc, this is particularly maddening because the side effects of these generics (eg, ketorolac, diclofenac) are much more commonly seen in my experience in patients with pre-existing dry eye syndrome (DES), decreasing the likelihood that they will take this important medicine.
In my patient population, I see an approximate 90% incidence of significant discomfort with the instillation of these drops, and we still see a very severe form of keratitis in more than 30% of patients after 7 days of treatment. This is scary for both patient and doctor, and the decreased vision that accompanies it can unfairly shake the confidence a patient has that her surgical outcome is good.
What to do? Well, the first thing to do is channel Nancy Reagan: Just say no! Do not write for or allow an after-the-fact change to ketorolac or diclofenac. Write for branded NSAIDs — safer, once-per-day regimens increases adherence — and if you must allow a substitution, only allow bromfenac, as the generic is as safe as the brand.
I’ve heard through the grapevine that Allergan will begin to produce and sell a generic version of the late, lamented Acular ST (ketorolac tromethamine ophthalmic solution, 0.4%); if this is the same formulation as the brand, it will be perfectly OK to use, even in DES patients, albeit four times per day.
Listen, this DES treatment stuff is hard enough without having to run the gauntlet of insurance payment-caused medication side effects. Stand up for your patient and yourself.