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Practitioners share pearls on new pharmaceuticals
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ORLANDO, Fla. – Here at Optometry’s Meeting, Ron Melton, OD, FAAO, and Randall Thomas, OD, MPH, FAAO, used interactive case reports to illustrate how they incorporate new therapeutics into their practice during a 2-hour continuing education course sponsored by Primary Care Optometry News.
A new steroid choice
The PCON Editorial Board members, who are in private practice in North Carolina, have begun prescribing Durezol (difluprednate ophthalmic emulsion 0.05%, Alcon) in patients for whom they previously prescribed Pred Forte (prednisolone acetate, Allergan) to ensure pharmacists fill the prescription as written.
“Pharmacists have this unrelenting desire to genericize everything,” Dr. Thomas said. Patients who he prescribed Pred Forte were receiving the generic version from the pharmacy, despite the fact that “no generic substitute” was marked on the prescription.
“I am writing Durezol now,” he said. “I believe it’s equally effective as Pred Forte, but with Pred Forte you have to treat every hour, whereas the emulsion vehicle in Durezol allows for less frequent dosing. With Durezol, there is no generic, so the doctor has prescription control.”
“In the setting of postoperative care, it will be interesting to see if it will be effective at twice daily,” Dr. Melton said, “then we could use nonsteroidals twice daily and the antibiotic twice daily. Patient compliance would increase.”
New antibiotic, antiviral
The lecture team discussed new antibiotics, including Allergan’s Zymaxid (gatifloxacin ophthalmic solution 0.5%), which is a stronger concentration of Zymar (gatifloxacin ophthalmic solution 0.3%, Allergan).
“We’re hoping this new concentration will be more effective,” Dr. Melton said.
“I’d use this new one instead of the 0.3%,” Dr. Thomas said.
Dr. Melton responded: “If you have a garden variety bacterial conjunctivitis, I think the 0.3% concentration would be appropriate.
The most recent topical ophthalmic antibiotic to come to market is a new chemical entity: a chlorofluoroquinolone, the doctors said.
“Besivance (besifloxacin 0.6% ophthalmic emulsion, Bausch + Lomb) is unique as a highly viscous emulsion with enhanced ocular surface residence time thanks to its Durasite vehicle,” Dr. Thomas said. “It can be used two or three times a day for conjunctivitis and perhaps every 2 hours for corneal infections.
“This molecule is thought to be relatively resistance-proof because it has no systemic counterpart and, therefore, is exclusively for ophthalmic use,” he continued. “We think Besivance will evolve to be a major workhorse in combating ocular surface bacterial infections.”
Drs. Melton and Thomas made note of a new topical antiviral. “Traditionally we had topical Viroptic (trifluridine, Monarch) to treat herpes simplex keratitis, and now we’ve got a newer product, Zirgan (ganciclovir ophthalmic gel 0.15%, Bausch + Lomb),” they said.
“Zirgan probably will evolve to be the new gold standard,” Dr. Thomas said. “People with topical problems prefer topical medicine.
“Keep in mind that oral antivirals are wonderful medicines, are highly effective and are the cheapest way to treat herpes simplex keratitis,” he continued. “The orals include acyclovir, valacyclovir and famciclovir. All three oral antivirals are available generically. Valacyclovir has a longer half life, so it’s only dosed three times a day. Acyclovir is five times a day. Once the cost of valacyclovir gets close to acyclovir, I’ll abandon acyclovir for valacyclovir. But for now acyclovir is much less expensive.”
Many patients have chronic recurrent herpetic disease, Dr. Thomas said. “Studies have clearly shown that you can take one 500-mg tablet of valacyclovir or two 400-mg tablets of acyclovir, and it reduces the rate of recurrence by about 50%. These are safe, wonderful medicines. A 500-mg tablet of valacyclovir once a day for life is probably perfectly fine.”
Plaquenil screenings
Some patients with rheumatoid arthritis are treated with Plaquenil (hydroxychloroquine sulfate, Sanofi-Aventis), which can cause corneal and retinal changes. However, Plaquenil in high doses will cause maculopathy, Dr. Thomas said, but usually only if the patient is overtreated. “Annual screening for Plaquenil-induced maculopathy could be stopped if patients were treated with proper doses,” he said.
Dr. Melton said that a patient who is 5 feet 2 inches tall and weighs 110 pounds should not be on a full dosage – 400 mg a day – of Plaquenil. “You need to let the rheumatologist know you feel that, based on the current literature, this dosage will potentially create some retinal toxicity, and you can back that up with references,” he said.
“Consider 200 mg on alternate days, for an average of 300 mg a day,” Dr. Thomas added.