Prescription Formulas for the Pediatric Patient Pediatric Pharmacology and Pathology Valerie M. Kattouf O.D., F.A.A.O. Illinois College of Optometry Chief, Pediatric Binocular Vision Service Associate Professor No disclosures No conflict of interest April 2019 In the next hour……. ▪ Ocular Medications and Children ▪ Presentations of Pediatric Pathology Ocular Medications & Children ▪ The rules: – birth → 2 years old = 1/2 dose – 2-3 years old = 2/3 dose – > 3 years old = adult dose ▪ If only 50 % is absorbed may be 10x maximum dosage Ocular Medications & Children ▪ Pediatric systems differ in: – drug excretion kidney is the main site of drug excretion diminished 2° renal immaturity – biotransformation liver is organ for drug metabolism Impaired 2° enzyme immaturity Punctal Occlusion for 3-4 minutes ↓ systemic absorption by 40% Ocular Medications & Children ▪ Systemic absorption occurs through….. – Mucous membrane of Nasolacrimal Duct 80% of each gtt passing through NLD system is available for rapid systemic absorption by the nasal mucosa – Conjunctiva – Oropharynx – Digestive system (if swallowed) Modified by variation in Gastric pH, delayed gastric emptying & intestinal mobility – Skin (2° overflow from conjunctival sac) Greatest in infants Blood volume of neonate 1/20 adult Therefore absorbed meds are more concentrated at this age Ocular Medications & Children ▪ Ocular Meds with strongest potential for pediatric SE : – 10 % Phenylephrine – 2 % Epinephrine – 1 % Atropine – 2 % Cyclopentalate – 1 % Prednisone Ocular Medications & Children ▪ Distribution to Site of Action in Pediatric Patients determined by : – Size of body fluid compartment – Muscle mass – Fat storage – Tissue blood flow – Protein binding capabilities Ocular Medications & Children ▪ Package inserts warn ”safety and efficacy has not been established in children” FDA recognizes that accepted medical practice often includes prescribing medications for use in patient populations that are not included in approved labeling (PDR ophthalmology) Ocular Pharmaceuticals Side Effects of Diagnostic Pharmaceutical Agents in Children Medication Class Example Ocular/ Systemic Side Local Side Effect Effect Adrenergic Agonist Phenylephrine Conjunctival Hypertension, Blanching tachycardia, arrhythmias Cholinergic Agents Cyclopentalate Ocular irritation, Hyperactivity, Atropine follicular restlessness, Tropicamide conjunctivitis, delirium, seizures, GI cutaneous disturbance, hyperemia temperature elevation, respiratory depression ADMINISTRATION OF CYCLOPLEGIC IN CLINIC ▪ Cycloplegic Spray 0.5% Tropicamide 0.5% Cyclogel 2.5% Phenylephrine ▪ O’BRIEN Pharmacy 800-627-4360 Side Effects of Diagnostic Pharmaceutical Agents in Children ▪ Phenylephrine risks – Hyperthyroidism and cardiovascular problems may result is tachyarrhythmia ▪ Premature / ROP patients =  systemic side effects – Use Cyclomydril 0.2% cyclo / 1 % phenylephrine no increased blood pressure ▪ Cholinergic Agents – Education: parents may call with dilation concerns not expecting it to last into next day – Atropine toxicity more susceptible to Lightly pigmented Brain damage Down Syndrome Treatment with Atropine ▪ Proper patient selection… – Moderate-high hyperopia – Moderate amblyopia (20/100 or better visual acuity) ▪ Administration schedule – 1 gtt 1.0% Atropine sulfate daily vs. weekend only frequency of installation can be reduced as acuity improvement is observed minimal installation is one drop of 1% Atropine sulfate two times per week ▪ Side Effects / Emergency contact information Atropine Instillation for Amblyopia Our evaluation found that ________________________ has amblyopia of the right / left / both eyes. Amblyopia is reduced vision in an eye that has not received adequate or appropriate use during early childhood, often known as “lazy eye”, and has many causes which have been explained by your doctor. If not treated, the amblyopic eye may never develop good vision and may even be functionally blind. The treatment of amblyopia may require multiple therapy methods in which your doctor may prescribe occlusion therapy with patching or atropine instillation. Active amblyopia vision therapy may be recommended to enhance the effectiveness of occlusion therapy. Glasses are also prescribed in most cases. The following Atropine instillation program is prescribed: Prescription glasses should be worn for: full time / near activities / distance activities Install 1 Drop Atropine into the RIGHT / LEFT eye on the indicated days: Monday Tuesday Wednesday Thursday Friday Saturday Sunday ***please keep medication out of reach from other family members*** Special Instructions: ____________________________________________________________________________ Possible Atropine Ophthalmic Solution Side Effects: Burning/stinging/redness of the eye, eye irritation, or temporary blurred vision may occur. Most people do not experience serious side effects from using this medication. Tell your doctor immediately if any of these unlikely but serious side effects occur: dizziness, fainting, new or increased eye pressure/pain/swelling/discharge, rash, or itching/swelling (especially of the fact/tongue/throat. Rare, but very serious side effects include: slow/shallow breathing, mental/mood, fast/irregular heartbeat. Your next appointment is on ______________. If you have any questions, please feel free to contact us at (312) 949-7280 or after hours via our EMERGENCY number at (312) 225-6200. Ocular Pharmaceuticals Commonly Used Ocular Anti-Biotic Medications in Children Administration of Ocular Meds Ointment vs. Drops ▪ Ointment – blurred vision – contact dermatitis ▪ Drops – risk of systemic toxicity – contact time with cornea (diluted by tears) Ocular Medications & Children Anti-biotic Ointments Drug Age Approval Erythromycin > 2 months Tobrex > 2 months Ciloxan > 2 years Polysporin > 2 years Ocular Medications & Children Anti-biotic Ointments Drug Dosing Erythromycin qid Tobrex qid Ciloxan tid x 2 days, bid x 5 days Polysporin qid Ocular Medications & Children Anti-biotic Drops Drug Age Approval Polytrim 2 months Fluoroquinolones Besivance 1 yr Moxeza > 4 months Ciloxan 1 yr Ocuflox 1 yr Quixin 1 yr Vigamox 1 yr Zymaxid 1 yr Iquix 6 yr Other Antibiotics Azasite > 1 yr Gentamycin unknown Sulfacetamide unknown Ocular Medications & Children Anti-biotic Drops • Polytrim – Broad spectrum, effective, inexpensive • AzaSite – macrolide anti-biotic (Z-pack) • Prolonged ½ life - dosing schedule • 1 gtt q 8-12 hrs (tid) x 2 days • 1 gtt qd x 5 days • Broad spectrum, effective, expensive Ocular Medications & Children Anti-biotic Drops • Fluoroquinolones (concentration dependent) • Besivance (0.6%)– new, Advanced A-B Vehicle: DuraSite mucoadhesive – provides enhanced ocular surface residency time Dosing = tid (q 8 hrs) Pediatric schedule: AM → after school → at bed time • Ciloxan (0.3%) • Ocuflox (0.3%) • Moxeza (0.5%) prolonged contact due to gum base = bid dosing • Quixin (0.5%) • Vigamox (0.5%) no preservative • Zymar (0.3%) • Zymaxid (0.5%) ↑ concentration may enhance clinical results • Iquix (1.5%) Ocular Medications & Children Anti-biotic Drops Drug Dosing Polytrim qid Flouroquinolones Besivance tid Moxeza bid Ciloxan 1gtt q 2hrs x 2days, qid x 5 days Ocuflox 1gtt q 2hrs x 2days, qid x 5 days Quixin 1gtt q 2hrs x 2days, qid x 5 days Vigamox tid Zymar 1gtt q 2hrs x 2days, qid x 5 days Zymaxid 1gtt q 2hrs x 2days, qid x 5 days Azasite tid x 2days, qd x 5days Ocular Medications & Children Anti-biotic Drops Drug Dosing Polytrim qid Azasite tid x 2days, qd x 5days Besivance tid Moxeza bid Ciloxan qid Ocuflox qid Quixin qid Vigamox tid Zymar qid Zymaxid qid Anterior Segment Pathology Nasolacrimal Duct Obstruction Nasolacrimal Duct Obstruction ▪ Clinical Characteristics – 5-6% of newborns – Constant tearing – Redness irritation of lids – **With secondary conjunctivitis discharge injection swelling over innermost aspect of lower lid pain fever Nasolacrimal Duct Obstruction Etiology and Anatomy ▪ Incomplete opening of lower end of the NLD along side of nose between inner canthus of eyelid and inferior turbinate of the nasal cavity Nasolacrimal Duct Obstruction TREATMENT OPTIONS 1) Warm compress / Hydrostatic Massage 2) Topical Antibiotic Drops 3) Probing The Course of Nasolacrimal Duct Obstruction 1983 T. Otis Paul 55 infants diagnosed with NLDO prior to 3 month old Percentage of Spontaneous Resolution by 1 year of age 3 months - 15% 6 months - 46% 12 months - 93% Resolution of Congenital Nasolacrimal Duct Obstruction with Nonsurgical Management Pediatric Eye Disease Investigator Group ▪ Objective To determine how often nasolacrimal duct obstruction (NLDO) resolves with 6 months of nonsurgical management in infants aged 6 to <10 months old. ▪ Baseline Characteristics Evaluated Age gender Laterality specific clinical signs of NLDO ▪ Results At the 6-month examination, which was completed for 117 of the 133 eyes (88%), the NLDO had resolved without surgery in 77 eyes. None of the baseline characteristics we evaluated were found to be associated with resolution Primary Treatment of Nasolacrimal Duct Obstruction with Probing In Children Less Than Four Years Old Pediatric Eye Disease Investigator Group* ▪ Objective To report the outcome of nasolacrimal duct probing as the primary treatment of congenital nasolacrimal duct obstruction (NLDO) in children less than 4 years of age ▪ Participants Nine hundred fifty-five eyes of 718 children AGES 6 to <48 months no prior nasolacrimal surgical procedure with at least