Orals for Eye Care
Consult a definitive reference if you lack experience with a drug or if the patient has serious co-morbidity, reduced liver or renal function, or is pregnant or nursing.
A) Convert lbs to kilograms: (lb. −10%)/2 = kg
B) Antibiotic recommendations: listed in order of preference. See notes and warnings below
1) Lid problems
· Ocular rosacea
· Meibomian gland dysfunction
· Hordeolum
· Chlamydia
a) Doxycycline: inexpensive, effective, classic
b) Zithromax: moderate price, use if tetracycline problems or you want simple dosing for an acute problem
c) Biaxin: expensive, third choice
d) Tetracycline and erythromycin, inexpensive but not recommended
2) Acute infections with no fever or systemic Sx
· Preseptal cellulitis
· Dacryocystitis
· Hyperacute conjunctivitis
· Sinusitis
· Ear infections
a) Keflex: inexpensive, effective
b) Zithromax: moderate price, use for penicillin allergies
c) Dicloxacillin: moderate price
d) Augmentin: expensive, very effective, may cause diarrhea
e) Ceftin: expensive, good for deep complicated infections with multiple organisms
f ) Penicillin, amoxicillin, ampicillin, Bactrim: inexpensive but less effective
C) Penicillins
1) Dicloxacillin 250 or 500 mg
a) Indications: broad-spectrum bacterial infections, especially cellulitis. Little staph resistance
b) Contraindications: penicillin allergy
c) Adults: 250 – 500 mg qid 1 hr before or 2 hrs after meals
d) Children: 12 – 25 mg/kg daily, divided qid
e) Common side effects: allergy
2) Amoxicillin 250 or 500 mg
a) Indications: non-serious broad-spectrum bacterial infections, especially sinusitis
b) Contraindications: penicillin allergy, resistant staph
c) Adults: 250 – 500 mg qid, OK with meals
d) Children <20 kg: 20 – 40 mg/kg daily, divided qid
e) Common side effects: allergy, occasional GI upset and hyperactivity
3) Augmentin 250 or 500 mg (amoxicillin + clavulanic acid): now also in 200 and 400 mg strengths
a) Indications: serious or resistant broad-spectrum bacterial infections including beta lactamase staph, a more effective drug
b) Contraindications: penicillin allergy
c) Adults and children >40 kg: 500 mg bid
d) Children <40 kg: 20 – 40 mg/kg daily, divided bid
e) Common side effects: GI upset, diarrhea, allergy, rash
4) Penicillin VK 250 or 500 mg
a) Indications: gonorrhea, strep throat
b) Contraindications: penicillin allergy, organisms other than gonorrhea or strep
c) Adults: 500 mg qid, OK with food
d) Children: 15 – 50 mg/kg daily divided qid
e) Common side effects: allergy
D) Cephalosporins
1) Cephalexin (Keflex) 1st generation, 250 or 500 mg
a) Indications: most gram+ bacterial infections, cellulitis
b) Contraindications: 10% cross reaction with penicillin allergy, colitis
c) Adults: 250 – 500 mg qid, OK with food
d) Children: 25 – 50 mg/kg daily, divided qid
e) Common side effects: allergy, rash, polyarthritis, diarrhea
2) Cefuroxime (Ceftin) 2nd generation, 125, 250, 500 mg
a) Indications: deep and complicated infections by multiple organisms such as in sinusitis and ear infections
b) Contraindications: 10% cross reaction with penicillin allergy
c) Adults: 250 – 500 mg bid
d) Children: 250 mg bid with meal
e) Common side effects: diarrhea, nausea, vomiting
E) Sulfa
1) Bactrim (sulfa 400 mg + trimethoprim 80 mg), Bactrim DS (sulfa 800 mg + trimethoprim 160 mg), suspension (sulfa 200 mg + trimethoprim 40 mg, per 5 mL)
a) Indications: bacterial infection, consider if penicillin allergy and erythromycin causes nausea
b) Contraindications: many resistant organisms, sulfa allergies
c) Adults: 2 Bactrim bid or 1 Bactrim DS bid
d) Children: 40 mg/kg of sulfa, divided bid
e) Common side effects: Stevens-Johnson syndrome, colitis (rarely peripheral neuritis, depression, convulsions)
F) Macrolides
1) Zithromax 250 or 500 mg tablets, Z-Pack
a) Indications: broad-spectrum bacterial infections. Especially good as a back up for infected patients with penicillin allergies and ocular rosacea/meibomianitis patients intolerant of doxycycline. Drug of choice for chlamydia, 1, 1000 mg dose
b) Relative contraindications (coordinate with the medical doctor): concurrent use of theophylline, digoxin, warfarin
c) Adults: 500 mg qd first day, then 250 mg qd for 4 days, avoiding antacids, 1 hr before or 2 hrs after meals. Lasts 2 weeks in the body
d) Children >6 months: 10 mg/kg qd first day, then 5 mg/kg qd for 4 days
e) Common side effects: GI upset, abdominal pain, colitis
2) Biaxin 250 or 500 mg tabs
a) Indications: broad-spectrum bacterial infections. For more serious infections than Zithromax
b) Contraindications: concurrent use of theophylline, digoxin, lovastatin, cyclosporine, Norpace
c) Adults: 250 or 500 mg bid
d) Children >20 months:15 mg/kg/day divided bid
e) Common side effects: GI upset, headache, taste changes
3) Erythromycin 250, 333, 500 mg
a) Indications: chlamydia in young and child-bearing women, broad-spectrum infection and rosacea/meibomianitis. Inexpensive alternate drug for penicillin allergy patients and doxycycline intolerant patients
b) Relative contraindications (coordinate with medical doctor): concurrent use of theophylline, digoxin, cyclosporine, Norpace, prednisone
c) Adults: 1000 mg/day divided bid, tid, or qid, OK with meals
d) Children: 30 – 50 mg/kg daily divided qid
e) Common side effects: nausea is common
G) Tetracyclines
1) Doxycycline 50, 75, 100 mg
a) Indications: use in place of tetracycline for chlamydia, acne rosacea, meibomian gland disease, good broad-spectrum coverage for infections, good for penicillin allergic patients
b) Contraindications: children <age 8, and child-bearing women. Will discolor growing teeth. Avoid with concurrent anticoagulants
c) Adults or >100 lbs: 100 mg bid, avoid milk
d) Children >age 8: day 1, 2 mg/kg divided bid, then 1 mg/kg qd subsequent days
e) Common side effects: GI problems, pseudotumor, rashes, Candida vaginitis overgrowth, nail discoloration, anemia, dizziness, headache, loss of oral contraceptive effectiveness, photosensitivity (cover skin, wear sunglasses)
H) Antivirals
1) Acyclovir (Zovirax) 200 mg
a) Indications: for inexpensive treatment of herpes zoster and herpes simplex infection
b) Contraindications: difficulty with 5x dosing
c) Adults with herpes simplex: initially 200 mg 5x/day for 10 days, then 400 mg bid for up to 12 months
d) Adults with herpes zoster: 800 mg 5x/day for 10 days
e) Children >2 yrs: 20 mg/kg 5x/day up to 800 mg total per day
f ) Common side effects: headache, CNS changes in elderly, GI upset, vertigo, fatigue
2) Valtrex 500 mg caps (pro drug of acyclovir)
a) Indications: more convenient treatment of herpes zoster and herpes simplex infection
b) Contraindications: cost, concurrent use of probenecid (gout Tx), cimetidine (Tagamet)
c) Adults with herpes simplex: 1000 mg bid for 10 days, then 500 mg bid for acute ocular herpes. 500 mg bid for suppression of recurrences
d) Adults with herpes zoster: 1000 mg tid for 7 days
e) Children: not recommended
f ) Common side effects: GI upset, headache, dizziness
3) Famvir 125, 250, 500 mg tabs
a) Indications: more convenient treatment of herpes simplex and herpes zoster infections
b) Contraindications: cost
c) Adults with herpes simplex: 125 mg bid until cleared
d) Adults with herpes zoster: 500 mg tid for 7 days
e) Children: not recommended
f ) Common side effects: GI upset, insomnia, dizziness, nervousness, fatigue
I) Antihistamines
1) Loratadine (Claritin) 10 mg: now over-the-counter (OTC)
a) Indications: non-sedating antihistamine for the relief of seasonal allergic Sx. Onset within 1 hr, lasts 24 hrs
b) Contraindications: non-specific
c) Adults and >age 6: 1, 10 mg tab 1 hr before or 2 hrs after meal qd
d) Children <age 6: not recommended
e) Common side effects: GI upset, mucosal dryness, blur, headache, fatigue, sleepiness, hyperkinesia
2) Loratadine + pseudoephedrine sulfate Claritin-D 24 hr 10/240 mg and Claritin-D 12 hr 5/120 mg)
a) Indications: non-sedating antihistamine and decongestant for the relief of seasonal allergic Sx. If decongestant causes insomnia, use 12 hr version in a.m. and Benadryl in p.m. to aid sleep
b) Relative contraindications: hypertension, diabetes, ischemic heart disease, narrow angle glaucoma, hyperthyroidism, seizures
c) Adults and >age 6: 1 tab, 1 hr before or 2 hrs after meal. Once per day for the 24 hr version and bid for the 12 hr version
d) Children <age 6: not recommended
e) Common side effects: GI upset, mucosal dryness, blur, headache, fatigue, insomnia, sleepiness, hyperkinesia, appetite suppression, bronchospasm
3) Cetirizine hydrochloride (Zyrtec) 5 or 10 mg tablets and syrup
a) Indications: non-sedating antihistamine for the relief of allergic Sx
b) Contraindications: pregnancy, nursing mothers, renal failure
c) Adults: 10 mg qd
d) Children 6 – 11 yrs: 5 –10 mg qd
e) Children 2 – 5 yrs: ½ – 1 teaspoon per day
f ) Common side effects: sleepiness, fatigue, dry mouth
4) Cetirizine hydrochloride 5 mg and pseudoephrine hydrochloride 120 mg (Zyrtec-D 12 hour)
a) Indications: relief of allergic Sx with nasal congestion
b) Contraindications: narrow angle glaucoma, hypertension, use of MAO inhibitors (obsolete antidepressant) within 14 days
c) Adults: 1 tablet bid
d) Children <12: not recommended
e) Common side effects: sleepiness, fatigue, dry mouth
5) Diphenhydramine (Benadryl) caps 25 mg OTC
a) Indications: inexpensive relief of allergic Sx, especially acute and medication induced Sx, sedating
b) Contraindications: respiratory problems, narrow angle glaucoma, hyperthyroidism, hypertension, cardiovascular disease, GI or urinary obstruction
c) Adults: 25 – 50 mg qid
d) Children >6: 25 mg qid
e) Common side effects: sedation, dizziness, excitement, hypotension, GI upset
6) Diphenhydramine + pseudoephedrine (Benadryl allergy/congestion) caps 25 mg OTC
a) Indications: inexpensive relief of allergic Sx with nasal congestion
b) Contraindications: respiratory problems, narrow angle glaucoma, hyperthyroidism, hypertension, cardiovascular disease, GI or urinary obstruction within 2 weeks of MAO inhibitors (obsolete antidepressant)
c) Adults: 2 caps qid
d) Children >6: 1 cap qid
e) Common side effects: sedation, dizziness, excitement, hypotension, rash, GI upset, palpitations
J) Carbonic anhydrase inhibitors: (topical Trusopt is usually a better choice)
1) Methazolamide (Neptazane) 25 or 50 mg, 100 per bottle
a) Indications: for reduction of IOP. Fewer side effects than Diamox. Consider Trusopt or Azopt instead
b) Contraindications: sulfa allergy, concurrent steroid or aspirin use
c) Adults: 50 – 100 mg bid or tid
d) Children: not recommended
e) Common side effects: “tingling” of extremities, tinnitus, fatigue, taste change, GI upset
2) Acetazolamide (Diamox) 125 or 250 mg tabs, or 500 mg Diamox Sequels
a) Indications: for IOP reduction. Consider Trusopt or Azopt instead
b) Contraindications: sulfa allergy, chronic obstructive pulmonary disease, diabetes
c) Adults, chronic use: Diamox tablets 125 – 250 mg qid or Diamox Sequels 500 mg bid. In angle closure start with a 500 mg loading dose of Diamox (not Sequels)
d) Children: not recommended
e) Common side effects: drowsiness, fever, diuresis, malaise, paresthesias, tinnitus, GI distress, blood dyscrasias; half of Diamox patients drop out due to side effects. Diamox Sequels better tolerated
K) Osmotics
1) Glycerin (Osmoglyn) 50% solution
a) Indications: urgent relief of angle closure in non-diabetics. Maximum effect in 1 hr. Most effective
b) Contraindications: diabetes
c) Adults: 2 – 3 mL/kg of solution, flavored on ice
d) Children: 2 – 3 mL/kg of solution flavored on ice
e) Common side effects: nausea, diuresis, vomiting
L) Analgesics & anti-inflammatories
1) Ibuprofen (Advil, Medipren, Midol 200, Motrin, Nuprin) 200 mg per tab
a) Indications: relief of pain and inflammation
b) Contraindications: aspirin allergy, alcoholism, gastritis, ulcers, 3rd trimester of pregnancy (use Tylenol instead), concurrent use of other anti-inflammatories such as Celebrex
c) Adults: 600 – 800 mg tid with food
d) Children: 10 – 40 mg/kg tid with food
e) Common side effects: GI upset, dizziness, visual disturbances, photophobia
2) Naproxen (Naprosyn, Naprelan 250 mg, 375 mg, 500 mg) (Aleve 220 mg)
a) Indications: long acting inflammation and arthritis relief. Less effective than ibuprofen for pain
b) Contraindications: aspirin allergy, 3rd trimester of pregnancy (see ibuprofen)
c) Adults: 250 – 500 mg bid, up to 750 mg bid for short term if tolerated
d) Children: 10 mg/kg divided bid (usually ½ of 250 mg tabs)
e) Common side effects: GI upset, headache, dizziness, drowsiness, tinnitus, peptic ulcers and bleeding problems, photophobia, heart disease, stroke
3) Tylenol #3 (30 mg codeine + 325 mg acetaminophen)
a) Indications: inexpensive relief of moderately severe pain
b) Contraindications: drug abuser, concurrent alcohol use, use of MAO inhibitors (obsolete antidepressant) within 14 days
c) Adults: 1 – 2 caps every 4 hrs
d) Children: 0.5 mg/kg of codeine component
e) Common side effects: sedation, drowsiness, vomiting, constipation, respiratory depression, syncope
4) Celebrex 100 or 200 mg
a) Indications: arthritis and relief of acute pain. Similar to NSAIDs without stomach problems
b) Contraindications: sulfa, aspirin, or NSAID allergy
c) Adults: 200 mg bid with initial loading dose of 400 mg
d) Children: not recommended <18 yrs
e) Common side effects: GI upset or pain, blurred vision, increased IOP, cataracts, heart disease, stroke
5) Ultram 50 mg
a) Indications: relief of moderately severe pain. Non-narcotic but works like narcotics with low risk of addiction. Easy on stomach
b) Contraindications: opioid allergy, intoxication
c) Adults 16 – 75 yrs: 50 – 100 mg every 4 – 6 hrs unless liver disease: consider ½ of 50 mg tab for small women and elderly
d) Children: not recommended
e) Common side effects: dizziness, nausea, constipation, headache, somnolence, vomiting
6) Vicodin (5 mg hydrocodone bitartrate and 500 mg acetaminophen)
a) Indications: for relief of moderately severe pain
b) Contraindications: drug abusers, concurrent alcohol use, use of MAO inhibitors (obsolete antidepressant) within 14 days
c) Adults: 1 tab every 4 hrs
d) Children: not approved
e) Common side effects: depression of respiration and cough reflex, sleepiness
