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Doxycycline most common oral antibiotic prescribed in these optometric practices
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Doxycycline prescribed most often
Paul M. Karpecki, OD, FAAO: The oral medication I prescribe most often is oral doxycycline 100 mg twice daily. This medication is interesting in that its benefits are not its antibiotic properties (in fact there is broad resistance to this agent), but rather its anti-inflammatory capabilities. Studies have suggested that doxycycline’s benefits stem from the ability to accumulate in oil glands, to regulate staphylococcal enzymes such as lipase and its anti-inflammatory nature. This combination makes it a very effective drug for conditions associated with inflammation surrounding oil glands. Such pathologies include meibomian gland dysfunction, internal hordeolum, blepharitis and acne rosacea (sebaceous glands), as examples. Certainly, any tetracycline medication should be avoided in pregnant or nursing women as well as children. Patients should also be informed of the risk of phototoxicity, gastritis and the potential for this medication to chelate out in the presence of dairy products or antacids, and patients should be followed for the rare risk of pseudotumor cerebri.
Evoxac (cevimeline HCl, Daiichi) is a secretagogue that I recommend for patients with Sjögren’s syndrome. The xerostomia or dry mouth associated with this condition makes eating and even swallowing difficult for these patients. The most effective medication I have found for this condition is Evoxac 30 mg three times daily. As a secretagogue, it stimulates saliva and, to a lesser extent, tear production. It appears to have fewer side effects than Salagen (pilocarpine HCl, Boehringer Ingelheim).
Acyclovir is my choice for antiviral therapy, although there are merits to Famvir (famcyclovir, SmithKline Beecham) and Valtrex (valacyclovir, Glaxo Wellcome) that have made me look closer at these new prodrugs as my drug of choice. Price had originally made acyclovir my top antiviral, but recently the prices have come closer, and a 10-day zoster treatment is only about $40 more for Valtrex. It is still significant, but it is much closer than it used to be. The advantages of Valtrex are that it is a three times per day medication compared to five times for acyclovir (although I have not found compliance to be an issue in zoster treatment), the potential decrease in post-herpetic neuralgia and the fact that Valtrex is still very effective even beginning 72 hours after the onset. I also use these antivirals for prophylaxis in preventing a stromal keratitis recurrence (acyclovir 400 mg twice daily or Valtrex 1,000 mg per day) and in children with primary herpes simplex dendritic keratitis.
I use Zithromax (azithromycin, Pfizer) for bacterial conditions or 1,000 mg once (four tablets) or a Z-Pak for inclusion conjunctivitis. A Z-Pak can also be prescribed for adult bacterial infectious conditions such as dacryocystitis, preseptal cellulitis or bacterial sinusitis, and it has a safety profile that allows it to be used in pediatric conditions (200/5 mL 10 mg/kg on the first day followed by 5 mg/kg) such as otitis media or preseptal cellulitis.
Claritin (loratadine, Schering) every day is my drug of choice for systemic allergic rhinitis, and Claritin-D every day is my drug of choice for allergic sinusitis. The once-a-day dosage and the fact that it is available over the counter make it easy to prescribe. This non-sedating medication can still cause drying, so increasing artificial tears is important to not exacerbate the ocular condition. Pseudophedrine, which is found in Claritin-D, should be avoided in patients with hypertension.
Paul M. Karpecki, OD, FAAO, practices at Moyes Eye Center in Kansas City and is a Primary Care Optometry News Editorial Board member. He can be reached at Moyes Eye Center, Barry Medical Park, St. Luke’s Northland Campus, 5844 N.W. Barry Rd., Ste. 200, Kansas City, MO 64154; (816) 746-9800; fax: (816) 587-3555; e-mail: pkarpecki@kc.rr.com. He has no direct financial interest in any products he mentions, nor is he a paid consultant for any companies he mentions.
Doxycycline for a variety of conditions
Scot Morris, OD: My five favorite oral medications include the following:
Doxycycline: Without a doubt, this is probably my most prescribed prescription oral pharmaceutical agent. It works well for the treatment of a variety of conditions including infectious and inflammatory lid margin disease. I have found that for many stubborn cases of seborrheic blepharitis and secondary mixed-mechanism infectious/seborrheic blepharitis, 100 mg of doxycycline used once daily for 8 to 10 weeks works well in addition to the appropriate method of lid hygiene. In this situation, doxycycline is not used for its antibiotic properties but instead because it causes a decrease in abnormal lipase production and reduces the free fatty acid formation that causes the inflammation. We also know that it has an inhibitory effect on various metalloproteinases that results in further down-regulation of the inflammatory cascade. Doxycycline has the advantage over other macrolides in that it is better absorbed with fewer gastrointestinal side effects. From a refractive surgery standpoint, 100 mg/day of doxycycline for 1 week has become a mainstay in the postoperative regimen for PRK. The down-regulation of the inflammatory cascade may result in an increased re-epithelialization rate as well as a decrease in the rate of postoperative haze formation.
Flaxseed oil/fish oil: Though not what we traditionally think of in terms of oral pharmaceuticals, these omega-3 fatty acids are also agents that I use in the treatment of many patients with various ocular surface problems. Not only do the various forms of alpha-linoleic acid (EPA and DHA) have assorted antioxidant properties, they also cause changes in trans-free fatty acid production and, in many individuals, a change in their lipase action and free fatty acid characteristics. I believe that in many individuals, this has a positive impact on the quantity and quality of the lipid produced by the meibomian glands. I use 1,000 to 2,000 mg of flaxseed oil or fish oil for a period of at least 3 months, though I leave many patients on a maintenance dose of 1,000 mg for much longer.
Prednisone: In cases of severe acute uveitis, severe inflammatory keratitis or acute infectious ulcer involving the central corneal stroma, I will often prescribe 60 mg of oral prednisone with a 2-day interval taper to gain control of the inflammatory process and allow other topical agents an opportunity to have an effect.
Azithromycin: In the form of a “Z-pak,” this antibiotic is one of my favorite orals for treating periorbital pain associated with infectious sinusitis. I also use it often for nonspecific conjunctivitis in which Chlamydia is suspected.
Amoxicillin: I use 250 mg every 6 hours for 10 days for many forms of acute infectious lid disease including internal hordeola, chalazia and prophylactically for preseptal cellulitis.
Scot Morris, OD, can be reached at 24440 Pleasant Park Rd., Conifer, CO 80433; (303) 250-0376; fax: (303) 697-7578; e-mail: scbmorris@earthlink.net. He has no direct financial interest in any products he mentions, nor is he a paid consultant for any companies he mentions.
Doxycycline number one script
Bobby Christensen, OD, FAAO: Doxycycline 100 mg is by far the number one oral script written in our practice. We use it for meibomianitis, acne rosacea and recurrent erosions that are persistent. We are starting to use Periostat (doxycycline hyclate, CollaGenex) 20 mg more often for long-term doxycycline treatment for meibomianitis and acne rosacea.
Dicloxacillin is my primary choice of antibiotic for preseptal cellulitis and dacryocystitis. If patients are allergic to penicillins, I usually go with ciprofloxacin.
I use a 1,000-mg sachet of azithromycin for Chlamydia, and I use acylovir a few times a year for recurrent herpes simplex infections.
Bobby Christensen, OD, FAAO, is senior V.P. network administrator of Vision Source, LP. He is also in private practice at Heritage Park Vision Source, 6912 E. Reno #101, Midwest City, OK 73110; (405) 737-9685; fax: (405) 737-4339; e-mail: vsourcebc@cox.net. He has no direct financial interest in any products he mentions, nor is he a paid consultant for any companies he mentions.