treatment plan

Oral and Systemic Medications In Eye Care: Part I

BY WILLIAM TOWNSEND, OD
June 2001

Practitioners often overlook the importance of oral and systemic medications in managing conditions related to the eye. Despite the advantages of topical agents, sometimes systemic medications systemic when systemic medications are the preferred method for treating patients with ocular conditions.

Pain and Inflammation

The first step in managing patients in pain is a thorough case history and medications history. Focus on past history, specifically medication allergy, and sensitivity. Documented allergy to non-steroidal anti-inflammatories (NSAIDS) or narcotic analgesics should be noted. Identify individuals with a prior history of narcotics abuse and determine what other medications the patient is taking. NSAIDS such as aspirin can enhance the platelet-inhibiting properties of warfrin. NSAIDS also can exacerbate existing asthma. Understanding the entire medication and health profile of an individual is important in prescribing oral medications.

Pain is mediated by several different substances, but the most common mediators of pain are the prostaglandins. Some prosta-glandins are responsible for many inflammatory processes, which results in increased pain. Unlike histamine and serotonin, prosta-glandins must be synthesized. The process can be blocked by corticosteroids or by NSAIDS. In situations with an accompanying cellular response, such as in uveitis, steroids have the obvious edge. Topical NSAIDS are very useful in pre-treating patients prior to corneal foreign body removal and significantly reduce postoperative pain and discomfort, but oral NSAIDS are also often necessary for managing ocular pain and irritation.

The pain-relieving properties of NSAIDs are often underestimated. In a study of dental patients, 400 mg of ibuprofen were found to be superior to Tylenol with 60 mg codeine (Tylenol #4) in pain relief. NSAIDs exert their anti-inflammatory and antipyretic influence both peripherally and in the central nervous system. Oral acetaminophen is an NSAID that exerts its analgesic and antipyretic effect within the CNS, but does not have an effect peripherally. Patients with contraindications to typical NSAIDs can often benefit from the pain-relieving properties of oral acetaminophen. Unlike other NSAIDS, acetaminophin has no anti-inflammatory effects. Ibuprofen is generally prescribed for adults 400 to 800 mg q 6 hrs. The customary adult dosing for acetaminophen is 650 mg q 4 hrs.

Eye conditions rarely require long-term pain management with narcotics; NSAIDS are superior to some narcotics in relieving pain. But narcotics reduce the perception of pain and induce drowsiness. They cause respiratory depression and, if possible, should be avoided in patients with asthma and COPD. Gastrointestinal effects include constipation, emesis and nausea, but these are usually not a problem when treatment is limited to a few days. Patients on narcotics tend to be sedated and should be warned not to drive or use dangerous equipment while taking them. These effects are magnified with alcohol. Obviously, one should also avoid prescribing narcotics for patients with a known history of abuse or addiction.

In selecting a narcotic for short-term pain management, look for minimizing side effects and maximizing pain relief. Hydrocodone with acetaminophen (Lortab, Lorcet, Vicodin) is an excellent choice for severe eye-related pain. Typical dosing is 5 mg to 10 mg q 3 to 4 hrs. Tylenol with codeine (Tylenol #3, Tylen-ol #4) is also time-proven for managing pain and is generally prescribed q 4 to 6 hours for adults. Upcoming issues will address other oral medications and their use in eye care. 

Dr. Townsend is in private practice in Canyon, Texas, and is a consultant at the Amarillo VA Medical Center. E-mail him at drbill@1s.net