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U.S. Pharmacist Health Systems Edition Vol. 35, No. 4 April 2010
AP
R I L 20 1 0
T H E J O U R N A L F O R P H A R M A C I S T S E D U C AT I O N
2 CE Credits
Overview of Glaucoma
Management
Cataract and LASIK Surgery
Ocular Manifestations
of Systemic Diseases
Age-Related Macular Degeneration
Reporting Adverse Drug Events
New Products in This Issue:
Authorized Generics / Greenstone LLC Brimonidine / Falcon
Pharmaceuticals, Ltd. Dexilant / Takeda Pharmaceuticals
North America, Inc. Humalog / Eli Lilly and Company
Imiquimod Cream / Fougera Injectables / Pfizer Injectables
F OR FR EE C E, GO TO:
www.uspharmacist.com
A J O B S O N P U B L I C AT I O N
4/1/10 1:13 PM
The name
KAPIDEX (dexlansoprazole)
has changed to
Ordering Information
NDC#
PRODUCT
STRENGTH
SIZE
64764-171-30
DEXILANT
30 mg
30 ct
64764-175-30
DEXILANT
60 mg
30 ct
64764-175-90
DEXILANT
60 mg
90 ct
DEXILANT and KAPIDEX are trademarks of Takeda Pharmaceuticals North America, Inc.,
and are used under license by Takeda Pharmaceuticals America, Inc.
2010 Takeda Pharmaceuticals North America, Inc. LPD-01383 4/10 Printed in U.S.A.
Straight Talk
1
U.S. Pharmacist April 2010 www.uspharmacist.com
4/1/10 11:36 AM
Vol. 35 No. 4
PERFORATION
A suction ring
is applied to the
numbed eye
TEAR ALONG
LASIK Ey
e
Surgery
APR
IL 2010
Corrective Pro
cedure
to Improve Visi
on
MEDICAL ILLUSTRATI
ON: KRISTEN
WEINANDT
MARZEJON 2010
LASIK (laser-as
sisted
(myopia), farsighte in situ keratomileusis) is a type
dness (hyperopia),
of eye surgery designed
are all the result
to treat nearsigh
of an out-of-focus and astigmatism. These condition
LASIK surgery
s, known as refractio tedness
works by changing image when light is reflected through
n errors,
correctly, the eye
the shape of the
the cornea onto
can
cornea using a
the retina.
laser.
performed on millionsfocus more clearly and vision
improves. The LASIK Once the cornea is shaped
of Americans since
lar procedure with
surgical procedur
its FDA approval
patients who want
e has been
in 1998, and it
LASIK is an outpatie
to improve their
continues to be
vision.
a popunt surgery that takes
eye drops, and the
less
than 30 minutes.
eyelid is held open
The eye
lift, flatten, and
by an instrume
hold the cornea
nt while a suction is numbed using anesthetic
steady. A small
allowing the laser
ring
is placed on the
flap is cut
access to shape the
eye to
into place without
corneal tissue underne from the corneal tissue and
folded back,
stitches. After LASIK
ath.
protect the cornea
surgery is complete The flap of tissue is then pressed
during the healing
d, an eye shield
back
LASIK eye surgery
period.
is placed over the
is
not
eye to
for
everyone. There
including those
are
with chronic dry
eyes, thin corneas, many people who should not undergo
error (very poor
vision). Patients
LASIK,
considering LASIK changing refractions, and significa
complications, as
well as the typical
surgery must understa
nt refraction
reduce the need
nd the risks and
for glasses or contact results of a successful procedur
potential
e. For
who achieve 20/20
lenses, but it does
not guarantee perfect many, LASIK surgery can
they had expected vision with LASIK as measured
vision.
Even
those patients
. In addition, LASIK
on the eye chart
from aging and
may not see the
cannot correct
requires
sharp images
they require a retreatm reading glasses. Many patients presbyopia, the change in vision
that results
who undergo LASIK
ent (second surgery)
to achieve better
surgery also find
vision.
that
Copyright Jobson
Medical Informati
on LLC, 2010
cont inue d
PTA1004 LASIK
2_12bo.indd
2/16/10 3:49
PM
COVER IMAGE:
FEATURES
Senior Care
Age-Related Macular
Degeneration . . . . . . . . . . . . . . . . . . 26
This ocular disorder is the most common cause of
blindness in the developed world.
Suzanne Albrecht, PharmD, MSLIS
www.ekurie.com
In glaucoma, elevation in intraocular
pressure exerts force posteriorly to cause
both structural and functional damage
to the optic disc of the eye.
THIS MONTH
2 CE Credits
An Overview of Glaucoma
Management for Pharmacists . . . . 52
This chronic disease of the eye is
characterized by progressive neuropathy
of the optic nerve that can lead to
irreversible blindness if untreated or
inadequately treated.
Karen K. OBrien, BS Pharm, PharmD; Alan W. Y.
Chock, PharmD; and Catherine A. Opere, PhD
Pharmacy Law
HEALTH S Y S TE M S E DI TI ON
Ocular Manifestations of Systemic Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . HS-2
Diabetes, hypertension, and autoimmune disorders may have a secondary ocular component.
Nicholas Beyda, PharmD; David Cluck, PharmD; Katia E. Taba, MD, PhD; and Mark Middlebrooks, PharmD
CUSTOMER SERVICE
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2
U.S. Pharmacist April 2010 www.uspharmacist.com
4/1/10 1:18 PM
A.
Mylan Pharmaceuticals.*
With one of the most advanced transdermal development and manufacturing facilities in the
United Statesbrand or genericMylan is well-recognized as an innovator in transdermal
drug delivery technology. In fact, last year 65% of all generic patches dispensed in the U.S.
carried the Mylan name.*
We have developed more generic transdermal patches than any company in the U.S. and all
of our patches are designed with patient safety in mind. None have a bulky, liquid, gel-filled
reservoir, which eliminates any concern about the dangers associated with leakage, and
none have aluminum or other metals in their backing, which may cause potential burns in
MRI patients. So when you need generic transdermal patchesthink Mylan.
MYNMKT308
Vol. 35 No. 4
U.S. Pharmacist
A Jobson Publication
APR
IL 2010
Executive Editor
Robert Davidson
Senior Editor
Bonnie Ostrowski
Senior Associate Editor
Marjorie Borden
Consulting Clinical Editor
DEPARTMENTS
Straight Talk
Production Manager
Whats News . . . . . . . . . . . . . . . . . 6
Emelda Barea
Vice President,
Creative Services and Production
Monica Tettamanzi
Contemporary
Compounding
Generic Trends . . . . . . . . . . . . . . 50
Generic drug industry news.
Classified Advertising. . . . . . . . . 62
Mental
health 29%
Visual Impairment
in Adults . . . . . . . . . . . . . . . . . . . 24
CEO, Information Services Division
Marc Ferrara
Senior Vice President, Operations
Jeff Levitz
Severe
condition 2%
Cardiovascular
system 17%
Auditory
system 15%
Circulatory
system 11%
Mild
condition
16%
Nonrisky
condition
11%
Cerebrovascular
system 4%
Endocrine
system 6%
THINKSTOCK
Lorraine Orlando
U.S. Pharmacist
160 Chubb Avenue, Suite 306
Lyndhurst, NJ 07071
Phone: (201) 623-0999
Fax: (201) 623-0991
E-mail: editor@uspharmacist.com
Web: www.uspharmacist.com
Printed on paper containing an
average of 96 percent post-consumer
recycled waste.
4/1/10 1:18 PM
Im
here.
Fougera is proud to introduce Imiquimod Cream 5%. Another first approval in our
more than 160-year history of firsts. Available in unit-of-use foilpacs the innovative
packaging that helped make Fougera a leader in the industry. Imiquimod is just
one more example of how Fougera is dedicated to bringing patients the highest
quality in prescription generic topicals.
IMIQUIMOD CREAM 5%
AB Rated to Aldara *
0168-0432-24
24 single-use foilpacs
For complete product information, please see package insert. Copies of the
package insert can be obtained at www.fougera.com/ImHere or requested
by calling 1-800-645-9833.
* Aldara is a registered trademark of Graceway Pharmaceuticals, LLC
Whats News
U.S. Pharmacist
Editorial Board of Advisors
Joseph Bova, RPh
Community Pharmacy Owner,
Carys Pharmacy,
Dobbs Ferry, New York;
Member, NYS Board of Pharmacy
Carmen Catizone, RPh
Executive Director, National Association
of Boards of Pharmacy
John M. Coster, PhD, RPh
Senior VP of Government Affairs,
National Community Pharmacists Assoc.
Hewitt (Ted) W. Matthews, PhD
Dean, Southern School of Pharmacy,
Mercer University, Atlanta
David G. Miller, RPh
Pharmacy Affairs, Merck & Co., Inc.,
West Point, Pennsylvania
Mario F. Sylvestri, PharmD, PhD
Senior Director, Medical Science Liaisons,
Amylin Pharmaceuticals
Ray A. Wolf, PharmD
Medical Education, Sanofi Aventis
Mary Ann E. Zagaria,
PharmD, MS, CGP
Senior Care Consultant and
President, MZ Associates, Inc.,
Norwich, New York
Contributing Editors
Loyd V. Allen, Jr., PhD
Connie Barnes, PharmD
Bruce Berger, PhD
R. Keith Campbell, RPh, CDE
Patrick N. Catania, PhD, RPh
R. Rebecca Couris, PhD, RPh
Ed DeSimone, PhD, RPh
Ronald W. Maddox, PharmD
Somnath Pal, BS (Pharm), MBA, PhD
W. Steven Pray, PhD, DPh
M. Saljoughian, PharmD, PhD
Jesse C. Vivian, BS Pharm, JD
3/31/10 1:39 PM
Printed in U.S.A.
41-1017217rR2 3/10
Rx Only
should be used with caution in such patients [see Dosage and Administration]. Potential for Interaction with Monoamine Oxidase InhibitorsIn patients receiving serotonin reuptake inhibitor drugs in combination with a monoamine oxidase inhibitor (MAOI), there have been reports of
serious, sometimes fatal, reactions including hyperthermia, rigidity, myoclonus, autonomic instability with possible rapid fluctuations of vital
signs, and mental status changes that include extreme agitation progressing to delirium and coma. These reactions have also been reported in
patients who have recently discontinued SSRI treatment and have been started on an MAOI. Some cases presented with features resembling
neuroleptic malignant syndrome. Furthermore, limited animal data on the effects of combined use of SSRIs and MAOIs suggest that these drugs
may act synergistically to elevate blood pressure and evoke behavioral excitation. Therefore, it is recommended that Lexapro should not be used
in combination with an MAOI, or within 14 days of discontinuing treatment with an MAOI. Similarly, at least 14 days should be allowed after
stopping Lexapro before starting an MAOI. Serotonin syndrome has been reported in two patients who were concomitantly receiving linezolid,
an antibiotic which is a reversible non-selective MAOI.
ADVERSE REACTIONS: Clinical Trials Experience-Because clinical studies are conducted under widely varying conditions, adverse reaction
rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect
the rates observed in practice. Clinical Trial Data Sources; Pediatrics (6 -17 years)-Adverse events were collected in 576 pediatric patients
(286 Lexapro, 290 placebo) with major depressive disorder in double-blind placebo-controlled studies. Safety and effectiveness of Lexapro in
pediatric patients less than 12 years of age has not been established. Adults-Adverse events information for Lexapro was collected from 715
patients with major depressive disorder who were exposed to escitalopram and from 592 patients who were exposed to placebo in double-blind,
placebo-controlled trials. An additional 284 patients with major depressive disorder were newly exposed to escitalopram in open-label trials. The
adverse event information for Lexapro in patients with GAD was collected from 429 patients exposed to escitalopram and from 427 patients
exposed to placebo in double-blind, placebo-controlled trials. Adverse events during exposure were obtained primarily by general inquiry and
recorded by clinical investigators using terminology of their own choosing. Consequently, it is not possible to provide a meaningful estimate of
the proportion of individuals experiencing adverse events without first grouping similar types of events into a smaller number of standardized
event categories. In the tables and tabulations that follow, standard World Health Organization (WHO) terminology has been used to classify
reported adverse events. The stated frequencies of adverse reactions represent the proportion of individuals who experienced, at least once, a
treatment-emergent adverse event of the type listed. An event was considered treatment-emergent if it occurred for the first time or worsened
while receiving therapy following baseline evaluation. Adverse Events Associated with Discontinuation of Treatment; Major Depressive
Disorder; Pediatrics (6 -17 years)-Adverse events were associated with discontinuation of 3.5% of 286 patients receiving Lexapro and 1% of
290 patients receiving placebo. The most common adverse event (incidence at least 1% for Lexapro and greater than placebo) associated with
discontinuation was insomnia (1% Lexapro, 0% placebo). Adults-Among the 715 depressed patients who received Lexapro in placebo-controlled
trials, 6% discontinued treatment due to an adverse event, as compared to 2% of 592 patients receiving placebo. In two fixed-dose studies,
the rate of discontinuation for adverse events in patients receiving 10 mg/day Lexapro was not significantly different from the rate of discontinuation for adverse events in patients receiving placebo. The rate of discontinuation for adverse events in patients assigned to a fixed dose of
20 mg/day Lexapro was 10%, which was significantly different from the rate of discontinuation for adverse events in patients receiving 10 mg/day
Lexapro (4%) and placebo (3%). Adverse events that were associated with the discontinuation of at least 1% of patients treated with Lexapro,
and for which the rate was at least twice that of placebo, were nausea (2%) and ejaculation disorder (2% of male patients). Generalized Anxiety
Disorder; Adults-Among the 429 GAD patients who received Lexapro 10-20 mg/day in placebo-controlled trials, 8% discontinued treatment due
to an adverse event, as compared to 4% of 427 patients receiving placebo. Adverse events that were associated with the discontinuation of at
least 1% of patients treated with Lexapro, and for which the rate was at least twice the placebo rate, were nausea (2%), insomnia (1%), and
fatigue (1%). Incidence of Adverse Reactions in Placebo-Controlled Clinical Trials; Major Depressive Disorder; Pediatrics (6 -17 years)-The
overall profile of adverse reactions in pediatric patients was generally similar to that seen in adult studies, as shown in Table 2. However, the
following adverse reactions (excluding those which appear in Table 2 and those for which the coded terms were uninformative or misleading)
were reported at an incidence of at least 2% for Lexapro and greater than placebo: back pain, urinary tract infection, vomiting, and nasal
congestion. Adults-The most commonly observed adverse reactions in Lexapro patients (incidence of approximately 5% or greater and approximately twice the incidence in placebo patients) were insomnia, ejaculation disorder (primarily ejaculatory delay), nausea, sweating increased,
fatigue, and somnolence. Table 2 enumerates the incidence, rounded to the nearest percent, of treatment-emergent adverse events that occurred
among 715 depressed patients who received Lexapro at doses ranging from 10 to 20 mg/day in placebo-controlled trials. Events included are
those occurring in 2% or more of patients treated with Lexapro and for which the incidence in patients treated with Lexapro was greater than
the incidence in placebo-treated patients.
TABLE 2
Treatment-Emergent Adverse Reactions Observed with a Frequency of 2%
and Greater Than Placebo for Major Depressive Disorder
Adverse Reaction
Autonomic Nervous System Disorders
Dry Mouth
Sweating Increased
Central & Peripheral Nervous System Disorders
Dizziness
Gastrointestinal Disorders
Nausea
Diarrhea
Constipation
Indigestion
Abdominal Pain
General
Influenza-like Symptoms
Fatigue
Psychiatric Disorders
Insomnia
Somnolence
Appetite Decreased
Libido Decreased
Respiratory System Disorders
Rhinitis
Sinusitis
Urogenital
Ejaculation Disorder1,2
Impotence2
Anorgasmia3
Lexapro
(N=715)
Placebo
(N=592)
6%
5%
5%
2%
5%
3%
15%
8%
3%
3%
2%
7%
5%
1%
1%
1%
5%
5%
4%
2%
9%
6%
3%
3%
4%
2%
1%
1%
5%
3%
4%
2%
9%
3%
2%
<1%
<1%
<1%
Generalized Anxiety Disorder; Adults-The most commonly observed adverse reactions in Lexapro patients (incidence of approximately 5% or
greater and approximately twice the incidence in placebo patients) were nausea, ejaculation disorder (primarily ejaculatory delay), insomnia,
fatigue, decreased libido, and anorgasmia. Table 3 enumerates the incidence, rounded to the nearest percent of treatment-emergent adverse
events that occurred among 429 GAD patients who received Lexapro 10 to 20 mg/day in placebo-controlled trials. Events included are those
occurring in 2% or more of patients treated with Lexapro and for which the incidence in patients treated with Lexapro was greater than the
incidence in placebo-treated patients.
TABLE 3
Treatment-Emergent Adverse Reactions Observed with a Frequency of 2%
and Greater Than Placebo for Generalized Anxiety Disorder
Lexapro
Placebo
Adverse Reactions
(N=429)
(N=427)
Autonomic Nervous System Disorders
Dry Mouth
9%
5%
Sweating Increased
4%
1%
Central & Peripheral Nervous System Disorders
Headache
24%
17%
Paresthesia
2%
1%
Gastrointestinal Disorders
Nausea
18%
8%
Diarrhea
8%
6%
Constipation
5%
4%
Indigestion
3%
2%
Vomiting
3%
1%
Abdominal Pain
2%
1%
Flatulence
2%
1%
Toothache
2%
0%
General
Fatigue
8%
2%
Influenza-like Symptoms
5%
4%
Musculoskeletal System Disorder
Neck/Shoulder Pain
3%
1%
Psychiatric Disorders
Somnolence
13%
7%
Insomnia
12%
6%
Libido Decreased
7%
2%
Dreaming Abnormal
3%
2%
Appetite Decreased
3%
1%
Lethargy
3%
1%
Adverse Reactions
TABLE 3
Treatment-Emergent Adverse Reactions Observed with a Frequency of 2%
and Greater Than Placebo for Generalized Anxiety Disorder (continued)
Lexapro
(N=429)
Placebo
(N=427)
2%
1%
14%
6%
2%
2%
<1%
1%
Dose Dependency of Adverse Reactions-The potential dose dependency of common adverse reactions (defined as an incidence rate of 5% in
either the 10 mg or 20 mg Lexapro groups) was examined on the basis of the combined incidence of adverse events in two fixed-dose trials.
The overall incidence rates of adverse events in 10 mg Lexapro-treated patients (66%) was similar to that of the placebo-treated patients (61%),
while the incidence rate in 20 mg/day Lexapro-treated patients was greater (86%). Table 4 shows common adverse reactions that occurred in
the 20 mg/day Lexapro group with an incidence that was approximately twice that of the 10 mg/day Lexapro group and approximately twice that
of the placebo group.
Adverse Reaction
Insomnia
Diarrhea
Dry Mouth
Somnolence
Dizziness
Sweating Increased
Constipation
Fatigue
Indigestion
TABLE 4
Incidence of Common Adverse Reactions in Patients with Major
Depressive Disorder
Placebo
10 mg/day
(N=311)
Lexapro
(N=310)
4%
7%
5%
6%
3%
4%
1%
4%
2%
4%
<1%
3%
1%
3%
2%
2%
1%
2%
20 mg/day
Lexapro
(N=125)
14%
14%
9%
9%
7%
8%
6%
6%
6%
Male and Female Sexual Dysfunction with SSRIs-Although changes in sexual desire, sexual performance, and sexual satisfaction often occur
as manifestations of a psychiatric disorder, they may also be a consequence of pharmacologic treatment. In particular, some evidence suggests
that SSRIs can cause such untoward sexual experiences. Reliable estimates of the incidence and severity of untoward experiences involving
sexual desire, performance, and satisfaction are difficult to obtain, however, in part because patients and physicians may be reluctant to discuss
them. Accordingly, estimates of the incidence of untoward sexual experience and performance cited in product labeling are likely to underestimate their actual incidence.
Adverse Event
Ejaculation Disorder
(primarily ejaculatory delay)
Libido Decreased
Impotence
TABLE 5
Incidence of Sexual Side Effects in Placebo-Controlled Clinical Trials
Lexapro
In Males Only
(N=407)
12%
6%
2%
Placebo
(N=383)
1%
2%
<1%
In Females Only
Libido Decreased
Anorgasmia
(N=737)
3%
3%
(N=636)
1%
<1%
There are no adequately designed studies examining sexual dysfunction with escitalopram treatment. Priapism has been reported with all SSRIs.
While it is difficult to know the precise risk of sexual dysfunction associated with the use of SSRIs, physicians should routinely inquire about
such possible side effects. Vital Sign Changes-Lexapro and placebo groups were compared with respect to (1) mean change from baseline in
vital signs (pulse, systolic blood pressure, and diastolic blood pressure) and (2) the incidence of patients meeting criteria for potentially clinically significant changes from baseline in these variables. These analyses did not reveal any clinically important changes in vital signs associated
with Lexapro treatment. In addition, a comparison of supine and standing vital sign measures in subjects receiving Lexapro indicated that
Lexapro treatment is not associated with orthostatic changes. Weight Changes-Patients treated with Lexapro in controlled trials did not differ
from placebo-treated patients with regard to clinically important change in body weight. Laboratory Changes-Lexapro and placebo groups were
compared with respect to (1) mean change from baseline in various serum chemistry, hematology, and urinalysis variables, and (2) the incidence
of patients meeting criteria for potentially clinically significant changes from baseline in these variables. These analyses revealed no clinically
important changes in laboratory test parameters associated with Lexapro treatment. ECG Changes-Electrocardiograms from Lexapro (N=625),
racemic citalopram (N=351), and placebo (N=527) groups were compared with respect to (1) mean change from baseline in various ECG
parameters and (2) the incidence of patients meeting criteria for potentially clinically significant changes from baseline in these variables. These
analyses revealed (1) a decrease in heart rate of 2.2 bpm for Lexapro and 2.7 bpm for racemic citalopram, compared to an increase of 0.3 bpm
for placebo and (2) an increase in QTc interval of 3.9 msec for Lexapro and 3.7 msec for racemic citalopram, compared to 0.5 msec for
placebo. Neither Lexapro nor racemic citalopram were associated with the development of clinically significant ECG abnormalities. Other
Reactions Observed During the Premarketing Evaluation of Lexapro-Following is a list of treatment-emergent adverse events, as defined in the
introduction to the ADVERSE REACTIONS section, reported by the 1428 patients treated with Lexapro for periods of up to one year in doubleblind or open-label clinical trials during its premarketing evaluation. The listing does not include those events already listed in Tables 2 & 3, those
events for which a drug cause was remote and at a rate less than 1% or lower than placebo, those events which were so general as to be
uninformative, and those events reported only once which did not have a substantial probability of being acutely life threatening. Events are
categorized by body system. Events of major clinical importance are described in the Warnings and Precautions section. Cardiovascular - hypertension, palpitation. Central and Peripheral Nervous System Disorders - light-headed feeling, migraine. Gastrointestinal Disorders - abdominal
cramp, heartburn, gastroenteritis. General - allergy, chest pain, fever, hot flushes, pain in limb. Metabolic and Nutritional Disorders - increased
weight. Musculoskeletal System Disorders - arthralgia, myalgia jaw stiffness. Psychiatric Disorders - appetite increased, concentration impaired,
irritability. Reproductive Disorders/Female - menstrual cramps, menstrual disorder. Respiratory System Disorders - bronchitis, coughing, nasal
congestion, sinus congestion, sinus headache. Skin and Appendages Disorders - rash. Special Senses - vision blurred, tinnitus. Urinary System
Disorders - urinary frequency, urinary tract infection. Post-Marketing Experience; Adverse Reactions Reported Subsequent to the Marketing
of Escitalopram-The following additional adverse reactions have been identified from spontaneous reports of escitalopram received worldwide.
These adverse reactions have been chosen for inclusion because of a combination of seriousness, frequency of reporting, or potential causal
connection to escitalopram and have not been listed elsewhere in labeling. However, because these adverse reactions were reported voluntarily
from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug
exposure. These events include: Blood and Lymphatic System Disorders: anemia, agranulocytis, aplastic anemia, hemolytic anemia, idiopathic
thrombocytopenia purpura, leukopenia, thrombocytopenia. Cardiac Disorders: atrial fibrillation, bradycardia, cardiac failure, myocardial
infarction, tachycardia, torsade de pointes, ventricular arrhythmia, ventricular tachycardia. Ear and Labyrinth Disorders: vertigo Endocrine
Disorders: diabetes mellitus, hyperprolactinemia, SIADH. Eye Disorders: diplopia, glaucoma, mydriasis, visual disturbance. Gastrointestinal
Disorders: dysphagia, gastrointestinal hemorrhage, gastroesophageal reflux, pancreatitis, rectal hemorrhage. General Disorders and
Administration Site Conditions: abnormal gait, asthenia, edema, fall, feeling abnormal, malaise. Hepatobiliary Disorders: fulminant hepatitis,
hepatic failure, hepatic necrosis, hepatitis. Immune System Disorders: allergic reaction, anaphylaxis. Investigations: bilirubin increased,
decreased weight, electrocardiogram QT prolongation, hepatic enzymes increased, hypercholesterolemia, INR increased, prothrombin
decreased. Metabolism and Nutrition Disorders: hyperglycemia, hypoglycemia, hypokalemia, hyponatremia. Musculoskeletal and Connective
Tissue Disorders: muscle cramp, muscle stiffness, muscle weakness, rhabdomyolysis. Nervous System Disorders: akathisia, amnesia, ataxia,
choreoathetosis, cerebrovascular accident, dysarthria, dyskinesia, dystonia, extrapyramidal disorders, grand mal seizures (or convulsions),
hypoaesthesia, myoclonus, nystagmus, Parkinsonism, restless legs, seizures, syncope, tardive dyskinesia, tremor. Pregnancy, Puerperium and
Perinatal Conditions: spontaneous abortion. Psychiatric Disorders: acute psychosis, aggression, agitation, anger, anxiety, apathy, completed
suicide, confusion, depersonalization, depression aggravated, delirium, delusion, disorientation, feeling unreal, hallucinations (visual and
auditory), mood swings, nervousness, nightmare, panic reaction, paranoia, restlessness, self-harm or thoughts of self-harm, suicide attempt,
suicidal ideation, suicidal tendency. Renal and Urinary Disorders: acute renal failure, dysuria, urinary retention. Reproductive System and Breast
Disorders: menorrhagia, priapism. Respiratory, Thoracic and Mediastinal Disorders: dyspnea, epistaxis, pulmonary embolism, pulmonary
hypertension of the newborn. Skin and Subcutaneous Tissue Disorders: alopecia, angioedema, dermatitis, ecchymosis, erythema multiforme,
photosensitivity reaction, Stevens Johnson Syndrome, toxic epidermal necrolysis, urticaria. Vascular Disorders: deep vein thrombosis, flushing,
hypertensive crisis, hypotension, orthostatic hypotension, phlebitis, thrombosis.
DRUG INTERACTIONS: Serotonergic Drugs-Based on the mechanism of action of SNRIs and SSRIs including Lexapro, and the potential
for serotonin syndrome, caution is advised when Lexapro is coadministered with other drugs that may affect the serotonergic neurotransmitter
systems, such as triptans, linezolid (an antibiotic which is a reversible non-selective MAOI), lithium, tramadol, or St. Johns Wort [see Warnings
and Precautions]. The concomitant use of Lexapro with other SSRIs, SNRIs or tryptophan is not recommended. Triptans-There have been rare
postmarketing reports of serotonin syndrome with use of an SSRI and a triptan. If concomitant treatment of Lexapro with a triptan is clinically
warranted, careful observation of the patient is advised, particularly during treatment initiation and dose increases [see Warnings and
Precautions]. CNS Drugs- Given the primary CNS effects of escitalopram, caution should be used when it is taken in combination with other
centrally acting drugs. Alcohol-Although Lexapro did not potentiate the cognitive and motor effects of alcohol in a clinical trial, as with other
psychotropic medications, the use of alcohol by patients taking Lexapro is not recommended. Monoamine Oxidase Inhibitors (MAOIs)-[see
Contraindications and Warnings and Precautions]. Drugs That Interfere With Hemostasis (NSAIDs, Aspirin, Warfarin, etc.)-Serotonin release
by platelets plays an important role in hemostasis. Epidemiological studies of the case-control and cohort design that have demonstrated an
association between use of psychotropic drugs that interfere with serotonin reuptake and the occurrence of upper gastrointestinal bleeding have
also shown that concurrent use of an NSAID or aspirin may potentiate the risk of bleeding. Altered anticoagulant effects, including increased
bleeding, have been reported when SSRIs and SNRIs are coadministered with warfarin. Patients receiving warfarin therapy should be carefully
monitored when Lexapro is initiated or discontinued. Cimetidine-In subjects who had received 21 days of 40 mg/day racemic citalopram, combined administration of 400 mg/day cimetidine for 8 days resulted in an increase in citalopram AUC and Cmax of 43% and 39%, respectively. The
clinical significance of these findings is unknown. Digoxin-In subjects who had received 21 days of 40 mg/day racemic citalopram, combined
administration of citalopram and digoxin (single dose of 1 mg) did not significantly affect the pharmacokinetics of either citalopram or digoxin.
Lithium-Coadministration of racemic citalopram (40 mg/day for 10 days) and lithium (30 mmol/day for 5 days) had no significant effect on the
pharmacokinetics of citalopram or lithium. Nevertheless, plasma lithium levels should be monitored with appropriate adjustment to the lithium
dose in accordance with standard clinical practice. Because lithium may enhance the serotonergic effects of escitalopram, caution should
be exercised when Lexapro and lithium are coadministered. Pimozide and Celexa-In a controlled study, a single dose of pimozide 2 mg coadministered with racemic citalopram 40 mg given once daily for 11 days was associated with a mean increase in QTc values of approximately
10 msec compared to pimozide given alone. Racemic citalopram did not alter the mean AUC or Cmax of pimozide. The mechanism of this
pharmacodynamic interaction is not known. Sumatriptan-There have been rare postmarketing reports describing patients with weakness,
hyperreflexia, and incoordination following the use of an SSRI and sumatriptan. If concomitant treatment with sumatriptan and an SSRI (e.g.,
fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram, escitalopram) is clinically warranted, appropriate observation of the patient is advised.
Theophylline-Combined administration of racemic citalopram (40 mg/day for 21 days) and the CYP1A2 substrate theophylline (single dose
of 300 mg) did not affect the pharmacokinetics of theophylline. The effect of theophylline on the pharmacokinetics of citalopram was not
evaluated. Warfarin-Administration of 40 mg/day racemic citalopram for 21 days did not affect the pharmacokinetics of warfarin, a CYP3A4 substrate. Prothrombin time was increased by 5%, the clinical significance of which is unknown. Carbamazepine-Combined administration of
racemic citalopram (40 mg/day for 14 days) and carbamazepine (titrated to 400 mg/day for 35 days) did not significantly affect the pharmacokinetics of carbamazepine, a CYP3A4 substrate. Although trough citalopram plasma levels were unaffected, given the enzyme-inducing
properties of carbamazepine, the possibility that carbamazepine might increase the clearance of escitalopram should be considered if the two
drugs are coadministered. Triazolam-Combined administration of racemic citalopram (titrated to 40 mg/day for 28 days) and the CYP3A4
substrate triazolam (single dose of 0.25 mg) did not significantly affect the pharmacokinetics of either citalopram or triazolam. KetoconazoleCombined administration of racemic citalopram (40 mg) and ketoconazole (200 mg), a potent CYP3A4 inhibitor, decreased the Cmax and AUC of
ketoconazole by 21% and 10%, respectively, and did not significantly affect the pharmacokinetics of citalopram. Ritonavir-Combined administration of a single dose of ritonavir (600 mg), both a CYP3A4 substrate and a potent inhibitor of CYP3A4, and escitalopram (20 mg) did not affect
the pharmacokinetics of either ritonavir or escitalopram. CYP3A4 and -2C19 Inhibitors-In vitro studies indicated that CYP3A4 and -2C19 are the
primary enzymes involved in the metabolism of escitalopram. However, coadministration of escitalopram (20 mg) and ritonavir (600 mg), a
potent inhibitor of CYP3A4, did not significantly affect the pharmacokinetics of escitalopram. Because escitalopram is metabolized by multiple
enzyme systems, inhibition of a single enzyme may not appreciably decrease escitalopram clearance. Drugs Metabolized by Cytochrome
P4502D6-In vitro studies did not reveal an inhibitory effect of escitalopram on CYP2D6. In addition, steady state levels of racemic citalopram
were not significantly different in poor metabolizers and extensive CYP2D6 metabolizers after multiple-dose administration of citalopram,
suggesting that coadministration, with escitalopram, of a drug that inhibits CYP2D6, is unlikely to have clinically significant effects on escitalopram metabolism. However, there are limited in vivo data suggesting a modest CYP2D6 inhibitory effect for escitalopram, i.e., coadministration
of escitalopram (20 mg/day for 21 days) with the tricyclic antidepressant desipramine (single dose of 50 mg), a substrate for CYP2D6, resulted
in a 40% increase in Cmax and a 100% increase in AUC of desipramine. The clinical significance of this finding is unknown. Nevertheless, caution
is indicated in the coadministration of escitalopram and drugs metabolized by CYP2D6. Metoprolol-Administration of 20 mg/day Lexapro for
21 days in healthy volunteers resulted in a 50% increase in Cmax and 82% increase in AUC of the beta-adrenergic blocker metoprolol (given in a
single dose of 100 mg). Increased metoprolol plasma levels have been associated with decreased cardioselectivity. Coadministration of Lexapro
and metoprolol had no clinically significant effects on blood pressure or heart rate. Electroconvulsive Therapy (ECT)-There are no clinical
studies of the combined use of ECT and escitalopram.
USE IN SPECIFIC POPULATIONS: Pregnancy; Pregnancy Category C-In a rat embryo/fetal development study, oral administration of
escitalopram (56, 112, or 150 mg/kg/day) to pregnant animals during the period of organogenesis resulted in decreased fetal body weight and
associated delays in ossification at the two higher doses (approximately 56 times the maximum recommended human dose [MRHD] of
20 mg/day on a body surface area [mg/m2] basis). Maternal toxicity (clinical signs and decreased body weight gain and food consumption), mild
at 56 mg/kg/day, was present at all dose levels. The developmental no-effect dose of 56 mg/kg/day is approximately 28 times the MRHD on a
mg/m2 basis. No teratogenicity was observed at any of the doses tested (as high as 75 times the MRHD on a mg/m2 basis). When female rats
were treated with escitalopram (6, 12, 24, or 48 mg/kg/day) during pregnancy and through weaning, slightly increased offspring mortality and
growth retardation were noted at 48 mg/kg/day which is approximately 24 times the MRHD on a mg/m2 basis. Slight maternal toxicity (clinical
signs and decreased body weight gain and food consumption) was seen at this dose. Slightly increased offspring mortality was also seen at
24 mg/kg/day. The no-effect dose was 12 mg/kg/day which is approximately 6 times the MRHD on a mg/m2 basis. In animal reproduction
studies, racemic citalopram has been shown to have adverse effects on embryo/fetal and postnatal development, including teratogenic effects,
when administered at doses greater than human therapeutic doses. In two rat embryo/fetal development studies, oral administration of racemic
citalopram (32, 56, or 112 mg/kg/day) to pregnant animals during the period of organogenesis resulted in decreased embryo/fetal growth and
survival and an increased incidence of fetal abnormalities (including cardiovascular and skeletal defects) at the high dose. This dose was also
associated with maternal toxicity (clinical signs, decreased body weight gain). The developmental no-effect dose was 56 mg/kg/day. In a rabbit
study, no adverse effects on embryo/fetal development were observed at doses of racemic citalopram of up to 16 mg/kg/day. Thus, teratogenic
effects of racemic citalopram were observed at a maternally toxic dose in the rat and were not observed in the rabbit. When female rats were
treated with racemic citalopram (4.8, 12.8, or 32 mg/kg/day) from late gestation through weaning, increased offspring mortality during the first
4 days after birth and persistent offspring growth retardation were observed at the highest dose. The no-effect dose was 12.8 mg/kg/day. Similar
effects on offspring mortality and growth were seen when dams were treated throughout gestation and early lactation at doses 24 mg/kg/day.
A no-effect dose was not determined in that study. There are no adequate and well-controlled studies in pregnant women; therefore, escitalopram should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Pregnancy-Nonteratogenic Effects
Neonates exposed to Lexapro and other SSRIs or SNRIs, late in the third trimester, have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding. Such complications can arise immediately upon delivery. Reported clinical findings have included
respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypotonia, hypertonia,
hyperreflexia, tremor, jitteriness, irritability, and constant crying. These features are consistent with either a direct toxic effect of SSRIs and SNRIs
or, possibly, a drug discontinuation syndrome. It should be noted that, in some cases, the clinical picture is consistent with serotonin syndrome
[see Warnings and Precautions]. Infants exposed to SSRIs in late pregnancy may have an increased risk for persistent pulmonary hypertension
of the newborn (PPHN). PPHN occurs in 1-2 per 1000 live births in the general population and is associated with substantial neonatal
morbidity and mortality. In a retrospective, case-control study of 377 women whose infants were born with PPHN and 836 women whose infants
were born healthy, the risk for developing PPHN was approximately six-fold higher for infants exposed to SSRIs after the 20th week of gestation
compared to infants who had not been exposed to antidepressants during pregnancy. There is currently no corroborative evidence regarding the
risk for PPHN following exposure to SSRIs in pregnancy; this is the first study that has investigated the potential risk. The study did not include
enough cases with exposure to individual SSRIs to determine if all SSRIs posed similar levels of PPHN risk. When treating a pregnant woman
with Lexapro during the third trimester, the physician should carefully consider both the potential risks and benefits of treatment [see Dosage
and Administration]. Physicians should note that in a prospective longitudinal study of 201 women with a history of major depression who were
euthymic at the beginning of pregnancy, women who discontinued antidepressant medication during pregnancy were more likely to experience
a relapse of major depression than women who continued antidepressant medication. Labor and Delivery-The effect of Lexapro on labor and
delivery in humans is unknown. Nursing Mothers-Escitalopram is excreted in human breast milk. Limited data from women taking 10-20 mg
escitalopram showed that exclusively breast-fed infants receive approximately 3.9% of the maternal weight-adjusted dose of escitalopram and
1.7% of the maternal weight-adjusted dose of desmethylcitalopram. There were two reports of infants experiencing excessive somnolence,
decreased feeding, and weight loss in association with breastfeeding from a racemic citalopram-treated mother; in one case, the infant was
reported to recover completely upon discontinuation of racemic citalopram by its mother and, in the second case, no follow-up information was
available. Caution should be exercised and breastfeeding infants should be observed for adverse reactions when Lexapro is administered to a
nursing woman. Pediatric Use-Safety and effectiveness of Lexapro has not been established in pediatric patients (less than 12 years of age) with
Major Depressive Disorder. Safety and effectiveness of Lexapro has been established in adolescents (12 to 17 years of age) for the treatment of
major depressive disorder [see Clinical Studies]. Although maintenance efficacy in adolescent patients with Major Depressive Disorder has not
been systematically evaluated, maintenance efficacy can be extrapolated from adult data along with comparisons of escitalopram pharmacokinetic parameters in adults and adolescent patients. Safety and effectiveness of Lexapro has not been established in pediatric patients less than
18 years of age with Generalized Anxiety Disorder. Geriatric Use-Approximately 6% of the 1144 patients receiving escitalopram in controlled
trials of Lexapro in major depressive disorder and GAD were 60 years of age or older; elderly patients in these trials received daily doses of
Lexapro between 10 and 20 mg. The number of elderly patients in these trials was insufficient to adequately assess for possible differential
efficacy and safety measures on the basis of age. Nevertheless, greater sensitivity of some elderly individuals to effects of Lexapro cannot
be ruled out. SSRIs and SNRIs, including Lexapro, have been associated with cases of clinically significant hyponatremia in elderly patients,
who may be at greater risk for this adverse event [see Hyponatremia]. In two pharmacokinetic studies, escitalopram half-life was increased by
approximately 50% in elderly subjects as compared to young subjects and Cmax was unchanged [see Clinical Pharmacology]. 10 mg/day is the
recommended dose for elderly patients [see Dosage and Administration]. Of 4422 patients in clinical studies of racemic citalopram, 1357 were
60 and over, 1034 were 65 and over, and 457 were 75 and over. No overall differences in safety or effectiveness were observed between these
subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger
patients, but again, greater sensitivity of some elderly individuals cannot be ruled out.
DRUG ABUSE AND DEPENDENCE: Abuse and Dependence; Physical and Psychological Dependence-Animal studies suggest that the abuse
liability of racemic citalopram is low. Lexapro has not been systematically studied in humans for its potential for abuse, tolerance, or physical
dependence. The premarketing clinical experience with Lexapro did not reveal any drug-seeking behavior. However, these observations were not
systematic and it is not possible to predict on the basis of this limited experience the extent to which a CNS-active drug will be misused, diverted, and/or abused once marketed. Consequently, physicians should carefully evaluate Lexapro patients for history of drug abuse and follow such
patients closely, observing them for signs of misuse or abuse (e.g., development of tolerance, incrementations of dose, drug-seeking behavior).
OVERDOSAGE: Human Experience-In clinical trials of escitalopram, there were reports of escitalopram overdose, including overdoses of up
to 600 mg, with no associated fatalities. During the postmarketing evaluation of escitalopram, Lexapro overdoses involving overdoses of over
1000 mg have been reported. As with other SSRIs, a fatal outcome in a patient who has taken an overdose of escitalopram has been rarely
reported. Symptoms most often accompanying escitalopram overdose, alone or in combination with other drugs and/or alcohol, included
convulsions, coma, dizziness, hypotension, insomnia, nausea, vomiting, sinus tachycardia, somnolence, and ECG changes (including QT
prolongation and very rare cases of torsade de pointes). Acute renal failure has been very rarely reported accompanying overdose. Management
of Overdose-Establish and maintain an airway to ensure adequate ventilation and oxygenation. Gastric evacuation by lavage and use of
activated charcoal should be considered. Careful observation and cardiac and vital sign monitoring are recommended, along with general
symptomatic and supportive care. Due to the large volume of distribution of escitalopram, forced diuresis, dialysis, hemoperfusion, and exchange
transfusion are unlikely to be of benefit. There are no specific antidotes for Lexapro. In managing overdosage, consider the possibility of
multiple-drug involvement. The physician should consider contacting a poison control center for additional information on the treatment of any
overdose.
Forest Pharmaceuticals, Inc.
Subsidiary of Forest Laboratories, Inc.
St. Louis, MO 63045 USA
Licensed from H. Lundbeck A/S
2009 Forest Laboratories, Inc.
Rev. 05/09
11
U.S. Pharmacist April 2010 www.uspharmacist.com
11 Consult 3_30sc.indd 11
3/31/10 1:40 PM
PATIENT INFORMATION
Common Questions About Contact Lenses
THINKSTOCK
PHARMACY STAMP
What Do I Need
to Know About
Cleaning My Lenses?
You should recall and follow strictly all instructions
given to you by your prescriber. Those relating to
11 Consult 4_1sc.indd 12
4/1/10 1:03 PM
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Risks of Wearing
Contact Lenses
Patients may ask pharmacists
about certain types of ocular
discomfort, each of which
may indicate irritation or
infection.4 These include discomfort, itching, burning,
pain, or swelling; a foreign
body sensation with a feeling
of grittiness; excessive tears or any
other ophthalmic discharge; extreme
sensitivity to light; unusual redness;
or blurred vision. If untreated, these
symptoms can lead to corneal ulceration, worsening of infection, and
blindness. Patients with these problems should be referred to their eye
care professional.
Safe Use of
Contact Lens Solutions
The sheer complexity of the contact
lens solution market defies discussion of individual products here.
However, both the FDA and CDC
provide several practical pieces of
advice that must be followed.8,9
Patients must understand that their
contact lens case can become a
breeding ground for infection if not
cleaned properly. They must empty
the solution out after every use.
Remaining solution is contaminated
and has reduced disinfectant capability. Each time lenses are removed
from the case, the patient should
clean and rinse the case, inverting it
to allow fluid to drain, and then
allow it to air-dry. Cases should be
replaced every 3 to 6 months.
In addition, patients should
understand that cleaning via rubbing and rinsing is superior to rinsing alone (i.e., the no rub method)
for cleaning lenses.10-12 To properly
rub and rinse, the wearer places
the disinfectant solution on the lens
while it lies in the palm. The solution is rubbed over the lens surface
for 5 to 10 seconds with the index
finger of the other hand. The lens is
then turned over and the process
repeated. A strong stream of disinfectant solution is sprayed over both
sides of the lens to remove debris,
14
U.S. Pharmacist April 2010 www.uspharmacist.com
11 Consult 3_30sc.indd 14
3/31/10 1:40 PM
Lens-Related Infections
Pharmacists may suspect infection
when patients complain of discomfort, itching, burning, severe pain,
photophobia, excessive tearing,
mucus discharge, blurred vision,
decreased visual acuity, swelling,
unusual redness, or a foreign body
sensation.8,13 The symptoms may be
confined to one eye only. This helps
differentiate infection from allergic
rhinitis, in which the eyes are pruritic, the discharge is watery, and
both eyes are affected equally due to
common allergen exposure.8
Bacterial infections are the most
common type in contact lens wearers. They include those caused by
Clostridium species (spp), Peptostreptococcus, Propionibacterium spp, and
Fusobacterium spp.14 In particular,
Pseudomonas infection is liable to be
a rapidly progressing condition causing the development of corneal
ulcers and blindness within 24 hours
if left untreated.10,15 Fungal infections (e.g., from Fusarium spp)
REFERENCES
1. Types of contact lenses. FDA. www.fda.gov/MedicalDevices/
ProductsandMedicalProcedures/HomeHealthandConsumer/
ConsumerProducts/ContactLenses/ucm062319.htm. Accessed
February 8, 2010.
2. Advantages and disadvantages of various types of contact lenses.
American Optometric Association. www.aoa.org/x5234.xml.
Accessed February 8, 2010.
3. Contact lens statistics and trends. The Optical Vision Site.
http://theopticalvisionsite.com/contact-lenses/contact-lens-statisticsand-trends/. Accessed March 26, 2010.
4. Contact lenses. Risks. FDA. www.fda.gov/MedicalDevices/
ProductsandMedicalProcedures/HomeHealthandConsumer/
ConsumerProducts/ContactLenses/ucm062589.htm. Accessed
February 8, 2010.
5. Contact lenses. Everyday eye care. FDA.
www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/
HomeHealthandConsumer/ConsumerProducts/ContactLenses/
ucm062594.htm. Accessed February 8, 2010.
6. Contact lens prescription. FDA. www.fda.gov/MedicalDevices/
ProductsandMedicalProcedures/HomeHealthandConsumer/
ConsumerProducts/ContactLenses/ucm062345.htm. Accessed
February 8, 2010.
15
U.S. Pharmacist April 2010 www.uspharmacist.com
11 Consult 3_30sc.indd 15
3/31/10 1:40 PM
Available in 5 strengths
Based on the first Fentanyl matrix in the world
Flatter patch
Fentanyl is combined with patch adhesive; no liquid reservoir
Eliminates accidental exposure to gel
Can be used during Magnetic Resonance Imaging (MRI)
You are encouraged to report negative side effects of
prescription drugs to the FDA. Visit www.fda.gov/medwatch,
or call 1-800-FDA-1088.
www.us.sandoz.com
a Novartis company
2010 Sandoz Inc.
SDZ0049
01DR10004
A suction ring
is applied to the
numbed eye
Corrective Procedure
to Improve Vision
LASIK (laser-assisted in situ keratomileusis) is a type of eye surgery designed to treat nearsightedness
(myopia), farsightedness (hyperopia), and astigmatism. These conditions, known as refraction errors,
are all the result of an out-of-focus image when light is reflected through the cornea onto the retina.
LASIK surgery works by changing the shape of the cornea using a laser. Once the cornea is shaped
correctly, the eye can focus more clearly and vision improves. The LASIK surgical procedure has been
performed on millions of Americans since its FDA approval in 1998, and it continues to be a popular procedure with patients who want to improve their vision.
LASIK is an outpatient surgery that takes less than 30 minutes. The eye is numbed using anesthetic
eye drops, and the eyelid is held open by an instrument while a suction ring is placed on the eye to
lift, flatten, and hold the cornea steady. A small flap is cut from the corneal tissue and folded back,
allowing the laser access to shape the corneal tissue underneath. The flap of tissue is then pressed back
into place without stitches. After LASIK surgery is completed, an eye shield is placed over the eye to
protect the cornea during the healing period.
LASIK eye surgery is not for everyone. There are many people who should not undergo LASIK,
including those with chronic dry eyes, thin corneas, changing refractions, and significant refraction
error (very poor vision). Patients considering LASIK surgery must understand the risks and potential
complications, as well as the typical results of a successful procedure. For many, LASIK surgery can
reduce the need for glasses or contact lenses, but it does not guarantee perfect vision. Even those patients
who achieve 20/20 vision with LASIK as measured on the eye chart may not see the sharp images
they had expected. In addition, LASIK cannot correct presbyopia, the change in vision that results
from aging and requires reading glasses. Many patients who undergo LASIK surgery also find that
they require a retreatment (second surgery) to achieve better vision.
Copyright Jobson Medical Information LLC, 2010
continued
2/16/10 3:49 PM
Candidates for Surgery: Often people are able to eliminate glasses or contact lenses for
everyday tasks after LASIK surgery, although their vision may not be perfect or even as clear
as it would be with corrective lenses. The majority of people who have LASIK surgery will
have 20/20 to 20/40 vision without glasses or contact lenses. Patients over 40 years of age
with presbyopia (problems focusing) will still require reading glasses after LASIK unless they
are corrected in one eye for close vision and one eye for distant vision, which is known as
monovision. Not all patients adjust well to monovision, so those considering this procedure
can try out this correction with a different-strength contact in each eye or different lenses in a
pair of glasses.
Some people have conditions that make them ineligible or poor candidates for success with
LASIK eye surgery. People with chronically dry eyes, inflammation of the eyelids, thin or damaged corneas, changing refractions, and significant refraction error (very poor vision) are not
good candidates for LASIK. Large pupils may also be a problem since halos and glare, two common complaints after LASIK surgery, may be more likely to occur. Pregnant or nursing women
or those people taking certain drugs that cause changes in refraction should not undergo LASIK.
People with diseases that affect the immune system (e.g., HIV/AIDS, diabetes, lupus) may have
trouble with corneal healing after surgery. LASIK is not a good choice for younger people with
changing refractions, especially those under age 18 to 21 years.
It is recommended that people considering LASIK discuss their daily work and leisure
activities with an eye surgeon when making the decision to undergo surgery. People who need
very sharp vision for detailed work or who drive frequently at night may not be satisfied with
the results. There is a significant waiting period before vision after LASIK is stable, usually up
to 6 months. There are also various waiting periods before wearing eye makeup, swimming, and
sports activities can be resumed.
Possible Side Effects: Common complaints after LASIK surgery include scratchy or dry eyes,
hazy vision, sensitivity to light, halos or glare, and problems seeing clearly at night. Many of
these effects improve over time, although in some people these are permanent. Less typical are
problems with visual correction or with the corneal flap that may require a second surgery.
Inflammation and infection can occur, but they are usually prevented by the use of prescription
eye drops. Rarely, vision is poorer after LASIK, and permanent loss of vision has occurred.
After LASIK surgery, eye drops are prescribed to prevent infection, decrease inflammation
and swelling, and soothe dryness. These eye drops must be used as prescribed by the eye surgeon
to prevent complications. Several follow-up appointments will be necessary to confirm that the
cornea is healing properly and vision is improving. If you have questions about using these eye
drops, ask your pharmacist.
2/16/10 3:49 PM
US100032
www.pfizerinjectables.com
THINKSTOCK
H E A LT H S YS T E M S E D I T I O N
Ocular Manifestations
of Systemic Diseases
any systemic diseases often have an ocular component that manifests secondarily. Patients with
ocular manifestations may first present in the
emergency department with relatively nonspecific symptoms
such as visual disturbance or eye pain. Unfortunately, many
ocular symptoms overlap in terms of the disease state they
may be attributed to. In some cases, however, the information obtained from an ocular examination may aid in the
differential diagnosis and appropriate management of the
underlying disease. While there are a significant number of
diseases known to present with ocular involvement, the aim
of this article is to provide a general overview of the commonly encountered ocular manifestations of systemic disease
in clinical practice and to review how they should be
approached therapeutically.
3/31/10 1:44 PM
OCULAR MANIFESTATIONS
HIV/AIDS
Approximately 33 million people are infected with HIV
worldwide.16 Opportunistic infections typically coincide
with the patients CD4 count; thus, they often present when
the CD4 count is 200 cells/mm3 or when the patient is
unaware of HIV infection.16 Therefore, CD4 count remains
the greatest predictor of ocular manifestations in HIV
patients. It is not uncommon for an HIV patient to experience an ocular complication at some point in his or her
lifetime. HIV infection places patients at risk for both infectious and noninfectious complications. The ocular manifestations of opportunistic infections are categorized based
on anatomical origin (orbital/adnexal manifestations [external] versus anterior/posterior segment manifestations [internal]) or nonspecific systemic infection.
A myriad of infections are associated with the adnexa of
the eye, including herpes zoster ophthalmicus (attributable
to reactivation of varicella-zoster virus [VZV] infection in
the first division of the fifth cranial nerve) and conjunctival
microvascular disease, which affects up to 75% to 80% of
patients.16 The most common manifestation is molluscum
contagiosum, a viral infection of the skin. Lastly, up to 20%
of patients who develop Kaposis sarcoma have ocular
manifestations, usually with adnexal involvement.16
As many as 20% of patients may experience damage to
the accessory and major lacrimal glands, resulting in keratoconjunctivitis sicca (dry eye).16 It should be noted that
dry eye is a relatively nonspecific symptom and can have a
number of causes, of which HIV is thought to be paramount.
Anterior segment manifestations are often attributable to
an infectious process, including infectious keratitis (bacterial,
fungal, or protozoal in nature) and iridocyclitis (associated
with cytomegalovirus [CMV] or VZV). Up to 50% of
H E A LT H S YS T E M S E D I T I O N
Hypertension
Hypertension, which occurs in approximately 50 million
people in the United States, remains a significant cause of
morbidity and a leading cause of cardiovascular mortality.12,13
Hypertension affects the eye in a multitude of ways, including vascular injury and increased risk of embolic events (e.g.,
central retinal vein and branch retinal artery occlusion).
The ocular manifestations of hypertension are commonly
classified as acute changes or chronic changes associated
with long-term systemic hypertension.13 The perpetual
increased pressure in the vasculature initiates a cascade of
events resulting in a change in the physiology of the eye.
This sequence of events, often collectively referred to as
hypertensive retinopathy, is the most common manifestation.14
The differences in the composition of the vasculature and
in anatomical location result in a different physiologic
response to increased blood pressure. In the acute phase,
hypertension predominantly affects the terminal arterioles;
in chronic hypertension, the observed circulatory changes
primarily involve the main retinal arterioles. Early manifestations include retinal hemorrhage, capillary obliteration,
and macular edema attributable to hypertensive choroidopathy. Long-standing hypertension can result in the development of compensatory shunt vessels and arteriovenous
nicking (impeded circulation in the retina).13
Hypertension also acts indirectly as a risk factor for
other ocular diseases. These include retinal vein occlusion,
retinal emboli, macroaneurysm, and optic neuropathy.
Hypertensive retinopathy is considered a reliable prognostic indicator of systemic disease. Perhaps the strongest
correlation is between hypertensive retinopathy and risk of
stroke. A study revealed that hypertensive retinopathy
increased stroke risk two- to fourfold when patients with
this condition were compared with patients who had no
retinopathy.15 Studies also suggest that hypertensive retinopathy can be used to predict incident congestive heart
failure, left ventricular hypertrophy, and renal impairment.13
The benefits of a fundoscopic examination are its ability
to predict underlying systemic disease (typically cardiovascular in nature) and its ability to assess the need for initiat-
Figure 1. A 45-year-old patient presented with severe vision loss due to diabetic macular edema. Reabsorption of hard exudates and
intraretinal hemorrhages was observed over 18 months. Treatment consisted of focal macular laser photocoagulation, intravitreal steroid
injection, improvement of glycemic control, and smoking cessation. Visual acuity improved from 20/200 to 20/40.
HS-3
U.S. Pharmacist April 2010 www.uspharmacist.com
3/31/10 1:44 PM
OCULAR MANIFESTATIONS
H E A LT H S YS T E M S E D I T I O N
Symptoms
Treatment
Keratoconjunctivitis
sicca
Keratitis
Episcleritis
Scleritis
3/31/10 1:44 PM
Patients, family members and caregivers should be instructed to keep patches (new and used) out of the reach
of children and others for whom fentanyl transdermal system was not prescribed. A considerable amount of active
fentanyl remains in fentanyl transdermal system even after use as directed. Accidental or deliberate application or
ingestion by a child or adolescent will cause respiratory depression that could result in death.
Cardiac Disease: Fentanyl may produce bradycardia. Fentanyl should be administered with caution to patients with
bradyarrhythmias.
Hepatic or Renal Disease: Insufficient information exists to make recommendations regarding the use of fentanyl
transdermal system in patients with impaired renal or hepatic function. If the drug is used in these patients, it should
be used with caution because of the hepatic metabolism and renal excretion of fentanyl.
Use in Pancreatic/Biliary Tract Disease: Fentanyl transdermal system may cause spasm of the sphincter of Oddi and
should be used with caution in patients with biliary tract disease, including acute pancreatitis. Opioids like fentanyl
transdermal system may cause increases in the serum amylase concentration.
Tolerance: Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drugs effects over time. Tolerance may occur to both the desired and undesired effects of
drugs, and may develop at different rates for different effects.
Physical Dependence: Physical dependence is a state of adaptation that is manifested by an opioid specific
withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the
drug, and/or administration of an antagonist. The opioid abstinence or withdrawal syndrome is characterized by some
or all of the following: restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, piloerection, myalgia,
mydriasis, irritability, anxiety, backache, joint pain, weakness, abdominal cramps, insomnia, nausea, anorexia,
vomiting, diarrhea, or increased blood pressure, respiratory rate, or heart rate. In general, opioids should not be
abruptly discontinued (see DOSAGE AND ADMINISTRATION: Discontinuation of Fentanyl Transdermal System in full
prescribing information).
Ambulatory Patients: Strong opioid analgesics impair the mental or physical abilities required for the performance of
potentially dangerous tasks, such as driving a car or operating machinery. Patients who have been given fentanyl
transdermal system should not drive or operate dangerous machinery unless they are tolerant to the effects of the drug.
Information for Patients: Patients and their caregivers should be provided with a Medication Guide each time
fentanyl transdermal system is dispensed because new information may be available.
Patients receiving fentanyl transdermal system should be given the following instructions by the physician:
1. Patients should be advised that fentanyl transdermal systems contain fentanyl, an opioid pain medicine
similar to morphine, hydromorphone, methadone, oxycodone, and oxymorphone.
2. Patients should be advised that each fentanyl transdermal system may be worn continuously for 72 hours, and
that each patch should be applied to a different skin site after removal of the previous transdermal patch.
3. Patients should be advised that fentanyl transdermal system should be applied to intact, nonirritated, and
nonirradiated skin on a flat surface such as the chest, back, flank, or upper arm. Additionally, patients should
be advised of the following:
In young children or persons with cognitive impairment, the patch should be put on the upper back to lower
the chances that the patch will be removed and placed in the mouth.
Hair at the application site should be clipped (not shaved) prior to patch application.
If the site of fentanyl transdermal system application must be cleansed prior to application of the patch,
do so with clear water.
Do not use soaps, oils, lotions, alcohol, or any other agents that might irritate the skin or alter its
characteristics.
Allow the skin to dry completely prior to patch application.
4. Patients should be advised that fentanyl transdermal system should be applied immediately upon removal from the
sealed package and after removal of the protective liner. Additionally the patient should be advised of the following:
The fentanyl transdermal system should not be used if the seal is broken or the patch is cut, damaged, or
changed in any way.
The transdermal patch should be pressed firmly in place with the palm of the hand for 30 seconds,
making sure the contact is complete, especially around the edges.
The patch should not be folded so that only part of the patch is exposed.
5. Patients should be advised that the dose of fentanyl transdermal system or the number of patches applied to
the skin should NEVER be adjusted without the prescribing healthcare professionals instruction.
6. Patients should be advised that while wearing the patch, they should avoid exposing the fentanyl transdermal
system application site and surrounding area to direct external heat sources, such as:
heating pads,
electric blankets,
sunbathing,
heat or tanning lamps,
saunas,
hot tubs or hot baths, and
heated water beds, etc.
7. Patients should also be advised of a potential for temperature-dependent increases in fentanyl release from the
patch that could result in an overdose of fentanyl; therefore, patients who develop a high fever or increased body
temperature due to strenuous exertion while wearing the patch should contact their physician.
8. Patients should be advised that if they experience problems with adhesion of the fentanyl transdermal system,
they may tape the edges of the patch with first aid tape. If problems with adhesion persist, patients may
overlay the patch with a transparent adhesive film dressing (e.g., Bioclusive or AskinaDerm).
9. Patients should be advised that if the patch falls off before 72 hours a new patch may be applied to a
different skin site.
10. Patients should be advised to fold (so that the adhesive side adheres to itself) and immediately flush down
the toilet used fentanyl transdermal systems after removal from the skin.
11. Patients should be advised that fentanyl transdermal system may impair mental and/or physical ability
required for the performance of potentially hazardous tasks (e.g., driving, operating machinery).
12. Patients should be advised to refrain from any potentially dangerous activity when starting on fentanyl
transdermal system or when their dose is being adjusted, until it is established that they have not been
adversely affected.
13. Patients should be advised that fentanyl transdermal system should not be combined with alcohol or other CNS
depressants (e.g., sleep medications, tranquilizers) because dangerous additive effects may occur, resulting
in serious injury or death.
14. Patients should be advised to consult their physician or pharmacist if other medications are being or will be
used with fentanyl transdermal system.
15. Patients should be advised of the potential for severe constipation.
16. Patients should be advised that if they have been receiving treatment with fentanyl transdermal system and
cessation of therapy is indicated, it may be appropriate to taper the fentanyl transdermal system dose, rather
than abruptly discontinue it, due to the risk of precipitating withdrawal symptoms.
17. Patients should be advised that fentanyl transdermal system contains fentanyl, a drug with high potential
for abuse.
18. Patients, family members and caregivers should be advised to protect fentanyl transdermal system from theft
or misuse in the work or home environment.
19. Patients should be instructed to keep fentanyl transdermal system in a secure place out of the reach of
children due to the high risk of fatal respiratory depression.
20. Patients should be advised that fentanyl transdermal system should never be given to anyone other than the
individual for whom it was prescribed because of the risk of death or other serious medical problems to that
person for whom it was not intended.
21. Patients should be informed that, if the patch dislodges and accidentally sticks to the skin of another person,
they should immediately take the patch off, wash the exposed area with water and seek medical attention for
the accidentally exposed individual.
22. When fentanyl transdermal system is no longer needed, the unused patches should be removed from their
pouches, folded so that the adhesive side of the patch adheres to itself, and flushed down the toilet.
23. Women of childbearing potential who become, or are planning to become pregnant, should be advised to
consult a physician prior to initiating or continuing therapy with fentanyl transdermal system.
24. Patients should be informed that accidental exposure or misuse may lead to death or other serious medical
problems.
Drug Interactions: Agents Affecting Cytochrome P450 3A4 Isoenzyme System: Fentanyl is metabolized mainly
via the human cytochrome P450 3A4 isoenzyme system (CYP3A4), therefore potential interactions may occur when
fentanyl transdermal system is given concurrently with agents that affect CYP3A4 activity. Coadministration with
agents that induce CYP3A4 activity may reduce the efficacy of fentanyl transdermal system. The concomitant use
of transdermal fentanyl with all CYP3A4 inhibitors (such as ritonavir, ketoconazole, itraconazole, troleandomycin,
clarithromycin, nelfanivir, nefazadone, amiodarone, amprenavir, aprepitant, diltiazem, erythromycin, fluconazole,
fasamprenavir, grapefruit juice, and verapamil) may result in an increase in fentanyl plasma concentrations, which
could increase or prolong adverse drug effects and may cause fatal respiratory depression. Patients receiving
fentanyl transdermal system and any CYP3A4 inhibitor should be carefully monitored for an extended period of time,
and dosage adjustments should be made if warranted (see BOX WARNING, CLINICAL PHARMACOLOGY: Drug
Interactions in full prescribing information, WARNINGS, and DOSAGE AND ADMINISTRATION in full prescribing
information for further information).
Central Nervous System Depressants: The concomitant use of fentanyl transdermal system with other central
nervous system depressants, including but not limited to other opioids, sedatives, hypnotics, tranquilizers (e.g.,
benzodiazepines), general anesthetics, phenothiazines, skeletal muscle relaxants, and alcohol, may cause respiratory
depression, hypotension, and profound sedation, or potentially result in coma or death. When such combined therapy
is contemplated, the dose of one or both agents should be significantly reduced.
MAO Inhibitors: Fentanyl transdermal system is not recommended for use in patients who have received MAOI within
14 days because severe and unpredictable potentiation by MAO inhibitors has been reported with opioid analgesics.
Carcinogenesis, Mutagenesis, and Impairment of Fertility: Studies in animals to evaluate the carcinogenic
potential of fentanyl HCl have not been conducted. There was no evidence of mutagenicity in the Ames Salmonella
mutagenicity assay, the primary rat hepatocyte unscheduled DNA synthesis assay, the BALB/c 3T3 transformation
test, and the human lymphocyte and CHO chromosomal aberration in vitro assays.
The potential effects of fentanyl on male and female fertility were examined in the rat model via two separate
experiments. In the male fertility study, male rats were treated with fentanyl (0, 0.025, 0.1 or 0.4 mg/kg/day) via
continuous intravenous infusion for 28 days prior to mating; female rats were not treated. In the female fertility study,
female rats were treated with fentanyl (0, 0.025, 0.1 or 0.4 mg/kg/day) via continuous intravenous infusion for
14 days prior to mating until day 16 of pregnancy; male rats were not treated. Analysis of fertility parameters in both
studies indicated that an intravenous dose of fentanyl up to 0.4 mg/kg/day to either the male or the female alone
produced no effects on fertility (this dose is approximately 1.6 times the daily human dose administered by a 100 mcg/hr
patch on a mg/m2 basis). In a separate study, a single daily bolus dose of fentanyl was shown to impair fertility in
rats when given in intravenous doses of 0.3 times the human dose for a period of 12 days.
Pregnancy: Teratogenic Effects: Pregnancy Category C: No epidemiological studies of congenital anomalies in
infants born to women treated with fentanyl during pregnancy have been reported.
The potential effects of fentanyl on embryo-fetal development were studied in the rat, mouse, and rabbit models.
Published literature reports that administration of fentanyl (0, 10, 100, or 500 mcg/kg/day) to pregnant female
Sprague-Dawley rats from day 7 to 21 via implanted microosmotic minipumps did not produce any evidence of
teratogenicity (the high dose is approximately 2 times the daily human dose administered by a 100 mcg/hr patch on
a mg/m2 basis). In contrast, the intravenous administration of fentanyl (0, 0.01, or 0.03 mg/kg) to bred female rats
from gestation day 6 to 18 suggested evidence of embryotoxicity and a slight increase in mean delivery time in the
0.03 mg/kg/day group. There was no clear evidence of teratogenicity noted.
Pregnant female New Zealand White rabbits were treated with fentanyl (0, 0.025, 0.1, 0.4 mg/kg) via intravenous
infusion from day 6 to day 18 of pregnancy. Fentanyl produced a slight decrease in the body weight of the live fetuses
at the high dose, which may be attributed to maternal toxicity. Under the conditions of the assay, there was no
evidence for fentanyl induced adverse effects on embryo-fetal development at doses up to 0.4 mg/kg (approximately
3 times the daily human dose administered by a 100 mcg/hr patch on a mg/m2 basis).
There are no adequate and well controlled studies in pregnant women. Fentanyl transdermal system should be
used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
Nonteratogenic Effects: Chronic maternal treatment with fentanyl during pregnancy has been associated with
transient respiratory depression, behavioral changes, or seizures characteristic of neonatal abstinence syndrome in
newborn infants. Symptoms of neonatal respiratory or neurological depression were no more frequent than expected
in most studies of infants born to women treated acutely during labor with intravenous or epidural fentanyl. Transient
neonatal muscular rigidity has been observed in infants whose mothers were treated with intravenous fentanyl.
The potential effects of fentanyl on prenatal and postnatal development were examined in the rat model. Female
Wistar rats were treated with 0, 0.025, 0.1, or 0.4 mg/kg/day fentanyl via intravenous infusion from day 6 of
pregnancy through 3 weeks of lactation. Fentanyl treatment (0.4 mg/kg/day) significantly decreased body weight in male
and female pups and also decreased survival in pups at day 4. Both the mid-dose and high-dose of fentanyl animals
demonstrated alterations in some physical landmarks of development (delayed incisor eruption and eye opening) and
transient behavioral development (decreased locomotor activity at day 28 which recovered by day 50). The mid-dose
and the high-dose are 0.4 and 1.6 times the daily human dose administered by a 100 mcg/hr patch on a mg/m2 basis.
Labor and Delivery: Fentanyl readily passes across the placenta to the fetus; therefore, fentanyl transdermal system
is not recommended for analgesia during labor and delivery.
Nursing Mothers: Fentanyl is excreted in human milk; therefore, fentanyl transdermal system is not recommended for
use in nursing women because of the possibility of effects in their infants.
Pediatric Use: The safety of fentanyl transdermal system was evaluated in three open-label trials in 291 pediatric
patients with chronic pain, 2 years of age through 18 years of age. Starting doses of 25 mcg/hr and higher were used
by 181 patients who had been on prior daily opioid doses of at least 45 mg/day of oral morphine or an equianalgesic
dose of another opioid. Initiation of fentanyl transdermal system therapy in pediatric patients taking less than
60 mg/day of oral morphine or an equianalgesic dose of another opioid has not been evaluated in controlled clinical
trials. Approximately 90% of the total daily opioid requirement (fentanyl transdermal system plus rescue medication)
was provided by fentanyl transdermal system.
Fentanyl transdermal system was not studied in children under 2 years of age.
Fentanyl transdermal system should be administered to children only if they are opioid-tolerant and 2 years of age
or older (see DOSAGE AND ADMINISTRATION in full prescribing information and BOX WARNING).
To guard against accidental ingestion by children, use caution when choosing the application site for fentanyl
transdermal system (see DOSAGE AND ADMINISTRATION in full prescribing information) and monitor adhesion of the
system closely.
Geriatric Use: Information from a pilot study of the pharmacokinetics of IV fentanyl in geriatric patients (N = 4)
indicates that the clearance of fentanyl may be greatly decreased in the population above the age of 60. The relevance
of these findings to fentanyl transdermal system is unknown at this time.
Respiratory depression is the chief hazard in elderly or debilitated patients, usually following large initial doses in
nontolerant patients, or when opioids are given in conjunction with other agents that depress respiration.
Fentanyl transdermal system should be used with caution in elderly, cachectic, or debilitated patients as they
may have altered pharmacokinetics due to poor fat stores, muscle wasting or altered clearance (see DOSAGE AND
ADMINISTRATION in full prescribing information).
ADVERSE REACTIONS: In post-marketing experience, deaths from hypoventilation due to inappropriate use of
fentanyl transdermal system have been reported (see BOX WARNING and CONTRAINDICATIONS).
Premarketing Clinical Trial Experience: Although fentanyl transdermal system use in postoperative or acute pain
and in patients who are not opioid-tolerant is CONTRAINDICATED, the safety of fentanyl transdermal system was
originally evaluated in 357 postoperative adult patients for 1 to 3 days and 153 cancer patients for a total of 510
patients. The duration of fentanyl transdermal system use varied in cancer patients; 56% of patients used fentanyl
transdermal system for over 30 days, 28% continued treatment for more than 4 months, and 10% used fentanyl
transdermal system for more than 1 year.
Hypoventilation was the most serious adverse reaction observed in 13 (4%) postoperative patients and in 3 (2%) of
the cancer patients. Hypotension and hypertension were observed in 11 (3%) and 4 (1%) of the opioid-naive patients.
Various adverse events were reported; a causal relationship to fentanyl transdermal system was not always
determined. The frequencies presented here reflect the actual frequency of each adverse effect in patients who
received fentanyl transdermal system. There has been no attempt to correct for a placebo effect, concomitant use of
Page 2 of 3
other opioids, or to subtract the frequencies reported by placebo-treated patients in controlled trials.
Adverse reactions reported in 153 cancer patients at a frequency of 1% or greater are presented in Table 1;
similar reactions were seen in the 357 postoperative patients.
In the pediatric population, the safety of fentanyl transdermal system has been evaluated in 291 patients with
chronic pain 2 to 18 years of age. The duration of fentanyl transdermal system use varied; 20% of pediatric patients
were treated for ) 15 days; 46% for 16 to 30 days; 16% for 31 to 60 days; and 17% for at least 61 days. Twenty-five
patients were treated with fentanyl transdermal system for at least 4 months and 9 patients for more than 9 months.
There was no apparent pediatric-specific risk associated with fentanyl transdermal system use in children as young
as 2 years old when used as directed. The most common adverse events were fever (35%), vomiting (33%), and
nausea (24%).
Adverse events reported in pediatric patients at a rate of * 1% are presented in Table 1.
TABLE 1: ADVERSE EVENTS (at rate of 1%)
Adults (N = 380) and Pediatric (N = 291) Clinical Trial Experience
Body System
Body as a Whole
Cardiovascular
Digestive
Nervous
Respiratory
Urogenital
Adults
Abdominal pain*, headache*, fatigue*,
back pain, fever, influenza-like symptoms*,
accidental injury, rigors
Arrhythmia, chest pain
Nausea**, vomiting**, constipation**,
dry mouth**, anorexia*, diarrhea*,
dyspepsia*, flatulence
Somnolence**, insomnia, confusion**,
asthenia**, dizziness*, nervousness*,
hallucinations*, anxiety*, depression*, euphoria*,
tremor, abnormal coordination, speech disorder,
abnormal thinking, abnormal gait,
abnormal dreams, agitation, paresthesia,
amnesia, syncope, paranoid reaction
Dyspnea*, hypoventilation*, apnea*,
hemoptysis, pharyngitis*, hiccups,
bronchitis, rhinitis, sinusitis,
upper respiratory tract infection*
Sweating**, pruritus*, rash, application site
reaction erythema, papules,
itching, edema
Urinary retention*, micturition disorder
Pediatrics
Pain*, headache*, fever,
syncope, abdominal pain,
allergic reaction, flushing
Hypertension, tachycardia
Nausea**, vomiting**,
constipation*, dry mouth,
diarrhea
Somnolence*, nervousness*,
insomnia*, asthenia*,
hallucinations, anxiety,
depression, convulsions,
dizziness, tremor, speech
disorder, agitation, stupor,
confusion, paranoid reaction
Dyspnea, respiratory
depression, rhinitis, coughing
The following adverse effects have been reported in less than 1% of the 510 adult postoperative and cancer
patients studied:
Cardiovascular: bradycardia
Digestive: abdominal distention
Nervous: aphasia, hypertonia, vertigo, stupor, hypotonia, depersonalization, hostility
Respiratory: stertorous breathing, asthma, respiratory disorder
Skin and Appendages, General: exfoliative dermatitis, pustules
Special Senses: amblyopia
Urogenital: bladder pain, oliguria, urinary frequency
Post-Marketing Experience: Adults: The following adverse reactions have been reported in association with the
use of fentanyl transdermal system and not reported in the premarketing adverse reactions section above:
Body as a Whole: edema
Cardiovascular: tachycardia
Metabolic and Nutritional: weight loss
Special Senses: blurred vision
Urogenital: decreased libido, anorgasmia, ejaculatory difficulty
DRUG ABUSE AND ADDICTION: Fentanyl transdermal system contains a high concentration of fentanyl, a potent
Schedule II opioid agonist. Schedule II opioid substances, which include hydromorphone, methadone, morphine,
oxycodone, and oxymorphone, have the highest potential for abuse and risk of fatal overdose due to respiratory depression. Fentanyl, like morphine and other opioids used in analgesia, can be abused and is subject to criminal diversion.
The high content of fentanyl in the patches (fentanyl transdermal system) may be a particular target for abuse
and diversion.
Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors
influencing its development and manifestations. It is characterized by behaviors that include one or more of the
following: impaired control over drug use, compulsive use, continued use despite harm, and craving. Drug addiction
is a treatable disease, utilizing a multidisciplinary approach, but relapse is common.
Drug seeking behavior is very common in addicts and drug abusers. Drug-seeking tactics include emergency
calls or visits near the end of office hours, refusal to undergo appropriate examination, testing or referral, repeated
loss of prescriptions, tampering with prescriptions and reluctance to provide prior medical records or contact
information for other treating physician(s). Doctor shopping to obtain additional prescriptions is common among
drug abusers and people suffering from untreated addiction.
Abuse and addiction are separate and distinct from physical dependence and tolerance. Physicians should be
aware that addiction may be accompanied by concurrent tolerance and symptoms of physical dependence. In addition,
abuse of opioids can occur in the absence of true addiction and is characterized by misuse for nonmedical
purposes, often in combination with other psychoactive substances. Since fentanyl transdermal system may be
diverted for nonmedical use, careful record keeping of prescribing information, including quantity, frequency, and
renewal requests is strongly advised.
Proper assessment of the patient, proper prescribing practices, periodic re-evaluation of therapy, and proper
dispensing and storage are appropriate measures that help to limit abuse of opioid drugs.
Fentanyl transdermal systems are intended for transdermal use (to be applied on the skin) only. Do not use a
fentanyl transdermal system if the seal is broken or the patch is cut, damaged, or changed in any way.
OVERDOSAGE: Clinical Presentation: The manifestations of fentanyl overdosage are an extension of its
pharmacologic actions with the most serious significant effect being hypoventilation.
Treatment: For the management of hypoventilation, immediate countermeasures include removing the fentanyl
transdermal system and physically or verbally stimulating the patient. These actions can be followed by
administration of a specific narcotic antagonist such as naloxone. The duration of hypoventilation following an
overdose may be longer than the effects of the narcotic antagonists action (the half-life of naloxone ranges from
30 to 81 minutes). The interval between IV antagonist doses should be carefully chosen because of the possibility
of renarcotization after system removal; repeated administration of naloxone may be necessary. Reversal of the
narcotic effect may result in acute onset of pain and the release of catecholamines.
Always ensure a patent airway is established and maintained, administer oxygen and assist or control
respiration as indicated and use an oropharyngeal airway or endotracheal tube if necessary. Adequate body
temperature and fluid intake should be maintained.
If severe or persistent hypotension occurs, the possibility of hypovolemia should be considered and managed
with appropriate parenteral fluid therapy.
OCULAR MANIFESTATIONS
ritis. Application of phenylephrine 10% will help distinguish
scleritis from episcleritis: Engorged vessels in episcleritis will
blanch, while those in scleritis will not.19 In RA, episcleritis
is more common than scleritis; however, scleritis tends to
be a more destructive process, with necrotizing scleritis with
inflammation being one presentation. It is important to
differentiate scleritis from episcleritis, as studies have documented a higher mortality rate and wider spread of systemic
disease in RA patients with scleritis.19
Page 3 of 3
MYLAN
Mylan Pharmaceuticals Inc.
Morgantown, WV 26505
HS-8
U.S. Pharmacist April 2010 www.uspharmacist.com
3/31/10 1:44 PM
H E A LT H S YS T E M S E D I T I O N
Cataract Surgery
Background
A cataract is an opacification of the lens of the eye. There
are three specific types of cataract: nuclear, cortical, and
posterior subcapsular. Cataract formation is mainly a
result of aging; it is generally seen in both lenses and is
caused by changes in the lens protein. Adult cataract is
typically seen in patients 50 years and older.1 Patients
aged over 50 years have a lower prevalence of cataract
development than patients aged 60 years and older.5-7
A cataract may be symptomatic or asymptomatic.
Symptoms include glare, decreased visual function or
blurred vision, and blindness. The incidence of blindness
from cataract is expected to increase owing to the increase
in life expectancy.8 Age is considered a nonmodifiable
risk factor. Other risk factors include genetics, suggesting
a hereditary nature to cataract; oral and inhaled corticosteroid use; the use of oral and topical beta-blockers; When Surgery Should Be Performed
dose- and drug-dependent use of phenothiazines such as Nonsurgical options prior to surgery have a limited role,
but include changing the patients
chlorpromazine and thioridazine; and
Brenda Wood, BSPharm, PharmD
9,10
Some
refractive correction.17 Other nonsurbusulfan alkylating agents.
Freelance Medical Writer
San Diego, California
data suggest that myopia may cause
gical options include magnifiers for
HS-9
U.S. Pharmacist April 2010 www.uspharmacist.com
3/31/10 1:44 PM
CATARACT SURGERY
H E A LT H S YS T E M S E D I T I O N
Preoperative: 1 wk
Postoperative: 4 wkseveral
mo, one drop 4 times/day
(ketorolac or diclofenac
ophthalmic drops)
Preoperative and
Postoperative Medication
Generally, it is the standard of care to
use topical nonsteroidal anti-inflammatory drugs (NSAIDs) pre- and postoperatively; however, there is no consensus
for the therapeutic use of topical
NSAIDs.17 According to an article by
OBrien, surgeons dose NSAIDs 1 to
2 days prior to surgery and for only 1
week to 10 days after surgery.20 Since
a major postoperative complication of
cataract surgery is cystoid macular edema
HS-10
U.S. Pharmacist April 2010 www.uspharmacist.com
3/31/10 1:44 PM
CATARACT SURGERY
REFERENCES
1. Resnikoff S, Pascolini D, Etyaale D, et al. Global data on visual impairment in
the year 2002. Bull World Health Organ. 2004;82:844-851.
2. Vision 2020. What is avoidable blindness? Cataract. www.vision2020.org/
main.cfm?type=WIBCATARACT.
3. Kahn HA, Leibowitz HM, Ganley JP. The Framingham Eye Study. I. Outline
and major prevalence findings. Am J Epidemiol. 1977;106:17-32.
4. Klein BE, Klein R, Linton KL. Prevalence of age-related lens opacities in a
population. The Beaver Dam Eye Study. Ophthalmology. 1992;99:546-552.
5. Varma R, Torres M. Prevalence of lens opacities in Latinos: The Los Angeles
Latino Eye Study. Ophthalmology. 2004;111:1449-1456.
6. Xu L, Cui T, Zhang S, et al. Prevalence and risk factors of lens opacities in
urban and rural Chinese in Beijing. Ophthalmology. 2006;113:747-755.
7. Murthy GVS, Gupta SK, Maraini G, et al. Prevalence of lens opacities in
north India: the INDEYE feasibility study. Invest Ophthalmol Vis Sci. 2007;
48:88-95.
8. Riaz Y, Mehta JS, Wormald R, et al. Surgical interventions for age-related cataract. Cochrane Database Syst Rev. 2006;(4):CD001323.
9. Kanthan GL, Wang JJ, Rochtchina E, Mitchell P. Use of antihypertensive medications and topical beta-blockers and the long-term incidence of cataract and cataract surgery. Br J Ophthalmol. 2009;93:1210-1214.
10. Li J, Tripathi RC, Tripathi BJ. Drug-induced ocular disorders. Drug Saf.
2008;31:127-141.
11. Abraham AG, Condon NG, West Gower E. The new epidemiology of cata-
Conclusion
Cataract is a prevalent condition in developed and developing countries. Adult cataract is typically seen in people
aged 50 years and older, and prevalence increases with
advancing age.1,5-7 In the U.S., approximately 40% to
46% of people over the age of 75 years will have vision
loss of 20/30 or worse as a result of cataract.4 Delaying
cataract by 10 years can have a significant impact on
quality of life while decreasing the economic burden.13
Negative outcomes of unresolved cataract include vision
loss, an increased rate of falls, fewer work opportunities,
and the inability to live independently.15,16 Surgery, which
is necessary to restore vision, results in rapid recovery
and a significant improvement in visual acuity, generally
seen in about 90% of patients.11 Identifying patients
with risk factors may lead to referral to an ophthalmologist and ultimately to receiving the cataract surgery
covered by Medicare.
There is no consensus on the use of topical NSAIDs
and topical corticosteroids pre- and postoperatively.17
Generally, NSAIDs are used pre-, intra-, and postoperatively. The Canadian Ophthalmological Society recommends that topical NSAIDs be started 2 to 3 days before
surgery and continued 3 to 4 times per day for 3 to 4
weeks.17 However, OBrien recommends a longer treatment duration of 4 weeks to several months for patients
at risk for CME.20
H E A LT H S YS T E M S E D I T I O N
HS-11
U.S. Pharmacist April 2010 www.uspharmacist.com
3/31/10 1:44 PM
Indication
Humalog is for use in patients with diabetes mellitus for
the control of hyperglycemia. Humalog should be used with
longer-acting insulin, except when used in combination
with sulfonylureas in patients with type 2 diabetes.
Indication
Humalog (insulin lispro injection [rDNA origin]) is for use in patients with diabetes mellitus for the control of
hyperglycemia. Humalog should be used with longer-acting insulin, except when used in combination with
sulfonylureas in patients with type 2 diabetes.
HI59950-4
HUMALOG
INSULIN LISPRO INJECTION (rDNA ORIGIN)
BRIEF SUMMARY: Consult package insert for complete prescribing information.
INDICATIONS AND USAGE: Humalog is an insulin analog that is indicated in the treatment of patients with
diabetes mellitus for the control of hyperglycemia. Humalog has a more rapid onset and a shorter duration of
action than regular human insulin. Therefore, in patients with type 1 diabetes, Humalog should be used in
regimens that include a longer-acting insulin. However, in patients with type 2 diabetes, Humalog may be used
without a longer-acting insulin when used in combination therapy with sulfonylurea agents.
Humalog may be used in an external insulin pump, but should not be diluted or mixed with any other
insulin when used in the pump. Humalog administration in insulin pumps has not been studied in patients
with type 2 diabetes.
CONTRAINDICATIONS: Humalog is contraindicated during episodes of hypoglycemia and in patients sensitive to
Humalog or any of its excipients.
WARNINGS: This human insulin analog differs from regular human insulin by its rapid onset of action as well
as a shorter duration of activity. When used as a mealtime insulin, the dose of Humalog should be given
within 15 minutes before or immediately after the meal. Because of the short duration of action of Humalog,
patients with type 1 diabetes also require a longer-acting insulin to maintain glucose control (except when
using an external insulin pump).
External Insulin Pumps: When used in an external insulin pump, Humalog should not be diluted or mixed
with any other insulin. Patients should carefully read and follow the external insulin pump manufacturers
instructions and the PATIENT INFORMATION leaet before using Humalog.
Physicians should carefully evaluate information on external insulin pump use in the Humalog physician
package insert and in the external insulin pump manufacturers instructions. If unexplained hyperglycemia or
ketosis occurs during external insulin pump use, prompt identication and correction of the cause is necessary.
The patient may require interim therapy with subcutaneous insulin injections (see PRECAUTIONS, For Patients
Using External Insulin Pumps, and DOSAGE AND ADMINISTRATION).
Hypoglycemia is the most common adverse effect associated with the use of insulins, including Humalog.
As with all insulins, the timing of hypoglycemia may differ among various insulin formulations. Glucose
monitoring is recommended for all patients with diabetes and is particularly important for patients using an
external insulin pump.
Any change of insulin should be made cautiously and only under medical supervision. Changes in insulin
strength, manufacturer, type (eg, regular, NPH, analog), species, or method of manufacture may result in the
need for a change in dosage.
PRECAUTIONS: GeneralHypoglycemia and hypokalemia are among the potential clinical adverse effects
associated with the use of all insulins. Because of differences in the action of Humalog and other insulins, care
should be taken in patients in whom such potential side effects might be clinically relevant (eg, patients who are
fasting, have autonomic neuropathy, or are using potassium-lowering drugs or patients taking drugs sensitive to
serum potassium level). Lipodystrophy and hypersensitivity are among other potential clinical adverse effects
associated with the use of all insulins.
As with all insulin preparations, the time course of Humalog action may vary in different individuals or at
different times in the same individual and is dependent on site of injection, blood supply, temperature, and
physical activity.
Adjustment of dosage of any insulin may be necessary if patients change their physical activity or their usual
meal plan. Insulin requirements may be altered during illness, emotional disturbances, or other stress.
HypoglycemiaAs with all insulin preparations, hypoglycemic reactions may be associated with the
administration of Humalog. Rapid changes in serum glucose concentrations may induce symptoms of
hypoglycemia in persons with diabetes, regardless of the glucose value. Early warning symptoms of
hypoglycemia may be different or less pronounced under certain conditions, such as long duration of diabetes,
diabetic nerve disease, use of medications such as beta-blockers, or intensied diabetes control.
Renal ImpairmentThe requirements for insulin may be reduced in patients with renal impairment.
Hepatic ImpairmentAlthough impaired hepatic function does not affect the absorption or disposition of
Humalog, careful glucose monitoring and dose adjustments of insulin, including Humalog, may be necessary.
AllergyLocal AllergyAs with any insulin therapy, patients may experience redness, swelling, or itching
at the site of injection. These minor reactions usually resolve in a few days to a few weeks. In some instances,
these reactions may be related to factors other than insulin, such as irritants in a skin cleansing agent or poor
injection technique.
Systemic AllergyLess common, but potentially more serious, is generalized allergy to insulin, which may
cause rash (including pruritus) over the whole body, shortness of breath, wheezing, reduction in blood pressure,
rapid pulse, or sweating. Severe cases of generalized allergy, including anaphylactic reaction, may be lifethreatening. Localized reactions and generalized myalgias have been reported with the use of cresol as an
injectable excipient. In Humalog-controlled clinical trials, pruritus (with or without rash) was seen in 17 patients
receiving Humulin R (N=2969) and 30 patients receiving Humalog (N=2944) (P=.053).
Antibody ProductionIn large clinical trials, antibodies that cross-react with human insulin and insulin lispro
were observed in both Humulin R- and Humalog-treatment groups. As expected, the largest increase in the
antibody levels during the 12-month clinical trials was observed with patients new to insulin therapy.
Usage of Humalog in External Insulin PumpsThe infusion set (reservoir syringe, tubing, and catheter),
Disetronic D-TRON2,3 or D-TRONplus2,3 cartridge adapter, and Humalog in the external insulin pump
reservoir should be replaced and a new infusion site selected every 48 hours or less. Humalog in the external
insulin pump should not be exposed to temperatures above 37C (98.6F).
In the D-TRON 2,3 or D-TRONplus 2,3 pump, Humalog 3 mL cartridges may be used for up to 7 days. However,
as with other external insulin pumps, the infusion set should be replaced and a new infusion site should be
selected every 48 hours or less.
When used in an external insulin pump, Humalog should not be diluted or mixed with any other insulin (see
INDICATIONS AND USAGE, WARNINGS, PRECAUTIONS, For Patients Using External Insulin Pumps, Mixing of
Insulins, DOSAGE AND ADMINISTRATION, and Storage).
Information for PatientsPatients should be informed of the potential risks and advantages of Humalog and
alternative therapies. Patients should also be informed about the importance of proper insulin storage, injection
technique, timing of dosage, adherence to meal planning, regular physical activity, regular blood glucose
monitoring, periodic hemoglobin A1C testing, recognition and management of hypoglycemia and hyperglycemia,
and periodic assessment for diabetes complications.
Patients should be advised to inform their physician if they are pregnant or intend to become pregnant.
Refer patients to the PATIENT INFORMATION leaet for timing of Humalog dosing (<
_15 minutes before or
immediately after a meal), storing insulin, and common adverse effects.
For Patients Using Insulin Pen Delivery Devices: Before starting therapy, patients should read the PATIENT
INFORMATION leaet that accompanies the drug product and the User Manual that accompanies the delivery
device. They should also reread these materials each time the prescription is renewed. Patients should be
instructed on how to properly use the delivery device, prime the Pen to a stream of insulin, and properly dispose
of needles. Patients should be advised not to share their Pens with others.
For Patients Using External Insulin Pumps: Patients using an external infusion pump should be trained in
intensive insulin therapy and in the function of their external insulin pump and pump accessories. Humalog was
tested in the MiniMed1 Models 506, 507, and 508 insulin pumps using MiniMed1 Polyn1 infusion sets.
Humalog was also tested in the Disetronic 2 H-TRONplus V100 insulin pump (with plastic 3.15 mL insulin
reservoir), and the Disetronic D-TRON 2,3 and D-TRONplus 2,3 insulin pumps (with Humalog 3 mL cartridges)
using Disetronic Rapid2 infusion sets.
The infusion set (reservoir syringe, tubing, catheter), D-TRON2,3 or D-TRONplus 2,3 cartridge adapter,
and Humalog in the external insulin pump reservoir should be replaced, and a new infusion site selected
every 48 hours or less. Humalog in the external pump should not be exposed to temperatures above
37C (98.6F).
A Humalog 3 mL cartridge used in the D-TRON 2,3 or D-TRONplus 2,3 pump should be discarded after 7 days,
even if it still contains Humalog. Infusion sites that are erythematous, pruritic, or thickened should be reported to
medical personnel, and a new site selected.
Humalog should not be diluted or mixed with any other insulin when used in an external insulin pump.
Laboratory TestsAs with all insulins, the therapeutic response to Humalog should be monitored by periodic
blood glucose tests. Periodic measurement of hemoglobin A1C is recommended for the monitoring of long-term
glycemic control.
Drug InteractionsInsulin requirements may be increased by medications with hyperglycemic activity, such
as corticosteroids, isoniazid, certain lipid-lowering drugs (eg, niacin), estrogens, oral contraceptives,
phenothiazines, and thyroid replacement therapy (see CLINICAL PHARMACOLOGY).
Insulin requirements may be decreased in the presence of drugs that increase insulin sensitivity or have
hypoglycemic activity, such as oral antidiabetic agents, salicylates, sulfa antibiotics, certain antidepressants
(monoamine oxidase inhibitors), angiotensin-converting-enzyme inhibitors, angiotensin II receptor blocking
agents, beta-adrenergic blockers, inhibitors of pancreatic function (eg, octreotide), and alcohol. Beta-adrenergic
blockers may mask the symptoms of hypoglycemia in some patients.
Mixing of InsulinsCare should be taken when mixing all insulins as a change in peak action may occur.
The American Diabetes Association warns in its Position Statement on Insulin Administration, On mixing,
physiochemical changes in the mixture may occur (either immediately or over time). As a result, the physiological
response to the insulin mixture may differ from that of the injection of the insulins separately. Mixing Humalog
with Humulin N or Humulin U does not decrease the absorption rate or the total bioavailability of Humalog.
Given alone or mixed with Humulin N, Humalog results in a more rapid absorption and glucose-lowering effect
compared with regular human insulin.
PregnancyTeratogenic EffectsPregnancy Category BReproduction studies with insulin lispro have
been performed in pregnant rats and rabbits at parenteral doses up to 4 and 0.3 times, respectively, the average
human dose (40 units/day) based on body surface area. The results have revealed no evidence of impaired
fertility or harm to the fetus due to Humalog. There are, however, no adequate and well-controlled studies with
Humalog in pregnant women. Because animal reproduction studies are not always predictive of human response,
this drug should be used during pregnancy only if clearly needed.
Although there are limited clinical studies of the use of Humalog in pregnancy, published studies with human
insulins suggest that optimizing overall glycemic control, including postprandial control, before conception and
during pregnancy improves fetal outcome. Although the fetal complications of maternal hyperglycemia have been
well documented, fetal toxicity also has been reported with maternal hypoglycemia. Insulin requirements usually
fall during the rst trimester and increase during the second and third trimesters. Careful monitoring of the
patient is required throughout pregnancy. During the perinatal period, careful monitoring of infants born to
mothers with diabetes is warranted.
Nursing MothersIt is unknown whether Humalog is excreted in signicant amounts in human milk. Many
drugs, including human insulin, are excreted in human milk. For this reason, caution should be exercised when
Humalog is administered to a nursing woman. Patients with diabetes who are lactating may require adjustments
in Humalog dose, meal plan, or both.
Pediatric UseIn a 9-month, crossover study of prepubescent children (n=60), aged 3 to 11 years,
comparable glycemic control as measured by A1C was achieved regardless of treatment group: regular human
insulin 30 minutes before meals 8.4%, Humalog immediately before meals 8.4%, and Humalog immediately
after meals 8.5%. In an 8-month, crossover study of adolescents (n=463), aged 9 to 19 years, comparable
glycemic control as measured by A1C was achieved regardless of treatment group: regular human insulin 30 to
45 minutes before meals 8.7% and Humalog immediately before meals 8.7%. The incidence of hypoglycemia
was similar for all 3 treatment regimens. Adjustment of basal insulin may be required. To improve accuracy in
dosing in pediatric patients, a diluent may be used. If the diluent is added directly to the Humalog vial, the shelf
life may be reduced (see DOSAGE AND ADMINISTRATION).
Geriatric UseOf the total number of subjects (n=2834) in 8 clinical studies of Humalog, 12% (n=338) were
65 years of age or over. The majority of these were patients with type 2 diabetes. A1C values and hypoglycemia
rates did not differ by age. Pharmacokinetic/pharmacodynamic studies to assess the effect of age on the onset
of Humalog action have not been performed.
ADVERSE REACTIONS: Clinical studies comparing Humalog with regular human insulin did not demonstrate a
difference in frequency of adverse events between the 2 treatments.
Adverse events commonly associated with human insulin therapy include the following:
Body as a Wholeallergic reactions (see PRECAUTIONS).
Skin and Appendagesinjection site reaction, lipodystrophy, pruritus, rash.
Otherhypoglycemia (see WARNINGS and PRECAUTIONS).
OVERDOSAGE: Hypoglycemia may occur as a result of an excess of insulin relative to food intake, energy
expenditure, or both. Mild episodes of hypoglycemia usually can be treated with oral glucose. Adjustments in
drug dosage, meal patterns, or exercise may be needed. More severe episodes with coma, seizure, or neurologic
impairment may be treated with intramuscular/subcutaneous glucagon or concentrated intravenous glucose.
Sustained carbohydrate intake and observation may be necessary because hypoglycemia may recur after
apparent clinical recovery.
DOSAGE AND ADMINISTRATION: Humalog is intended for subcutaneous administration, including use in select
external insulin pumps (see DOSAGE AND ADMINISTRATION, External Insulin Pumps). Dosage regimens of
Humalog will vary among patients and should be determined by the healthcare provider familiar with the
patients metabolic needs, eating habits, and other lifestyle variables. Pharmacokinetic and pharmacodynamic
studies showed Humalog to be equipotent to regular human insulin (ie, one unit of Humalog has the same
glucose-lowering effect as one unit of regular human insulin), but with more rapid activity. The quicker glucoselowering effect of Humalog is related to the more rapid absorption rate from subcutaneous tissue. An adjustment
of dose or schedule of basal insulin may be needed when a patient changes from other insulins to Humalog,
particularly to prevent premeal hyperglycemia.
When used as a mealtime insulin, Humalog should be given within 15 minutes before or immediately after a
meal. Regular human insulin is best given 30 to 60 minutes before a meal. To achieve optimal glucose control,
the amount of longer-acting insulin being given may need to be adjusted when using Humalog.
The rate of insulin absorption and consequently the onset of activity are known to be affected by the site of
injection, exercise, and other variables. Humalog was absorbed at a consistently faster rate than regular human
insulin in healthy male volunteers given 0.2 U/kg regular human insulin or Humalog at abdominal, deltoid, or
femoral sites, the 3 sites often used by patients with diabetes. When not mixed in the same syringe with other
insulins, Humalog maintains its rapid onset of action and has less variability in its onset of action among injection
sites compared with regular human insulin (see PRECAUTIONS). After abdominal administration, Humalog
concentrations are higher than those following deltoid or thigh injections. Also, the duration of action of Humalog
is slightly shorter following abdominal injection, compared with deltoid and femoral injections. As with all insulin
preparations, the time course of action of Humalog may vary considerably in different individuals or within the
same individual. Patients must be educated to use proper injection techniques.
Humalog in a vial may be diluted with STERILE DILUENT for Humalog, Humulin N, Humulin R, Humulin 70/30,
and Humulin R U-500 to a concentration of 1:10 (equivalent to U-10) or 1:2 (equivalent to U-50). Diluted
Humalog may remain in patient use for 28 days when stored at 5C (41F) and for 14 days when stored at 30C
(86F). Do not dilute Humalog contained in a cartridge or Humalog used in an external insulin pump.
Parenteral drug products should be inspected visually before use whenever the solution and the container
permit. If the solution is cloudy, contains particulate matter, is thickened, or is discolored, the contents must not
be injected. Humalog should not be used after its expiration date. The cartridge containing Humalog is not
designed to allow any other insulin to be mixed in the cartridge or for the cartridge to be relled with insulin.
External Insulin PumpsHumalog was tested in MiniMed1 Models 506, 507, and 508 insulin pumps using
MiniMed1 Polyn1 infusion sets. Humalog was also tested in the Disetronic 2 H-TRONplus V100 insulin
pump (with plastic 3.15 mL insulin reservoir) and the Disetronic D-TRON 2,3 and D-TRONplus 2,3 pumps (with
Humalog 3 mL cartridges) using Disetronic Rapid2 infusion sets. Humalog should not be diluted or mixed with
any other insulin when used in an external insulin pump.
HOW SUPPLIED:
Humalog (insulin lispro injection, USP [rDNA origin]) is available in the following package sizes (with each
presentation containing 100 units insulin lispro per mL [U-100]):
10 mL vials
NDC 0002-7510-01 (VL-7510)
3 mL vials
NDC 0002-7510-17 (VL-7533)
NDC 0002-7516-59 (VL-7516)
5 x 3 mL cartridges3
5 x 3 mL prelled insulin delivery devices (Pen)
NDC 0002-8725-59 (HP-8725)
Storage Unopened Humalog should be stored in a refrigerator (2 to 8C [36 to 46F]), but not in the
freezer. Do not use Humalog if it has been frozen. Unrefrigerated (below 30C [86F]) 12 vials, cartridges, Pens,
and KwikPens must be used within 28 days or be discarded, even if they still contain Humalog. Protect from
direct heat and light.
Use in an External Insulin PumpA Humalog 3mL cartridge used in the D-TRON2,3 or D-TRONplus2,3
should be discarded after 7 days, even if it still contains Humalog. Infusion sets, D-TRON 2,3 and D-TRONplus 2,3
cartridge adapters, and Humalog in the external insulin pump reservoir should be discarded every 48 hours
or less.
Literature revised December 7, 2009
KwikPens manufactured by Eli Lilly and Company, Indianapolis, IN 46285, USA.
Pens manufactured by Eli Lilly and Company, Indianapolis, IN 46285, USA or Lilly France,
F-67640 Fegersheim, France.
Vials manufactured by Eli Lilly and Company, Indianapolis, IN 46285, USA or Hospira, Inc.,
Lake Forest, IL 60045, USA or Lilly France, F-67640 Fegersheim, France.
Cartridges manufactured by Lilly France, F-67640 Fegersheim, France for Eli Lilly and Company,
Indianapolis, IN 46285, USA.
www.humalog.com
Copyright 1996, 2008, Eli Lilly and Company. All rights reserved.
H E A LT H S YS T E M S E D I T I O N
THINKSTOCK
Reporting
Adverse Drug
Events
decision by the FDA to approve a drug for market by federal law or regulation to submit reports of ADEs on
is based on a thorough review of that drugs safety any medical product, due to the challenges of enforcing
and efficacy to determine whether the benefits such a mandate.5 Many ADEs are likely never reported
outweigh the risks associated with its use. While clinical because they are not recognized as safety concerns, perhaps
trials help to establish the efficacy of a drug and to reveal because the HCP is unfamiliar with the reporting process
common adverse events, there are limitations in identifying and its importance. Moreover, incomplete fields or inacsafety concerns in this setting. For example, study participants curacies in the submitted data may limit the utility of the
may not necessarily represent real world patients receiving data.
Patients, HCPs, and the pharmaceutical industry all have
the drug once it is on the market. Pharmacovigilance involves
the continued monitoring of the safety profiles of products an interest in enhancing drug safety by reporting suspected
throughout their life cycles, and particularly once in the ADEs to the FDA. To encourage this, the FDA recently
marketplace, through scientific data-gathering activities released a final rule entitled, Toll-Free Number for Reportrelating to the detection, assessment, and understanding of ing Adverse Events on Labeling for Human Drug Products,
requiring the following statement to be distributed with
adverse events.
Adverse events are undesirable experiences associated dispensed new and refill prescription drugs: Call your
with the use of a medical product. In the regulatory setting, doctor for medical advice about side effects. You may report
adverse events are categorized as adverse drug events (ADEs) side effects to FDA at 1-800-FDA-1088.6 Moreover, the
and, as a subset of ADEs, adverse drug reactions (ADRs) recent focus on safety concerns surrounding several widely
used products has intensified the focus on the drug safety
(TABLE 1).1
It is challenging to estimate the true incidence of ADEs system, and timely and complete ADE reporting continues
in the general population, with uncertainty about the to be an integral component of this.
number of patients exposed to a given drug, poor docuThe aim of this article is to familiarize the reader with
mentation, and underreporting, as well as the effect of the process for ADE/ADR reporting for drugs currently in
publicity around a particular drug on the reported frequency the U.S. marketplace. This will include discussion of how
of an event. In 2008, the FDA received more than 530,000 the ADE reports are handled by the FDA and the pharmareports of suspected ADEs, of which some 33,000 were ceutical industry, and the measures currently being used
submitted directly to the FDA; most
and those under development to monitor
Mark
H.
Mayer,
PharmD,
MBA
2
were submitted by manufacturers.
patient safety. While there are global ADE
Principal Consultant in Global Scientific Policy
That same year, there were 320,000
reporting requirements, this article will
Eli Lilly and Company, Indianapolis, Indiana
serious adverse events and nearly
center on ADE reporting to the FDA. Also,
Sherie A. Dowsett, PhD
50,000 deaths.3 While reporting of Consultant in Global Medical Communications for simplicity of reading, the term ADE is
Eli Lilly and Company
ADEs is a vital component in ensurused throughout to encompass both ADEs
Brahmavar, PharmD
ing drug safety postapproval, the FDAs PharmacyKalpana
and ADRs.
Coordinator, St. Vincent Medical Center
Adverse Event Reporting System is Northeast, Indianapolis, Indiana. At the time of this
believed to capture only a small por- writing, Dr. Brahmavar was with Global Medical REPORTING OF ADVERSE EVENTS
Information, Eli Lilly and Company
THROUGH MEDWATCH
tion of ADEs that occur.4
Kenneth Hornbuckle, DVM, PhD
While adverse event reporting
MedWatch, established by the FDA in 1993,
Senior Epidemiology Advisor
Global Patient Safety, Eli Lilly and Company
guidelines are frequently in place at
was designed to expedite and broaden volWilliam P. Brookfield, MS, RPh
both institutional and professionaluntary reports of serious ADEs by HCPs
Consultant in Global Patient Safety
society levels, health care professionand manufacturers.7 The FDA requests that
Eli Lilly and Company
a serious ADE (i.e., the ADE is fatal, lifeals (HCPs) are currently not required
HS-15
U.S. Pharmacist April 2010 www.uspharmacist.com
4/1/10 1:12 PM
Table 2. Characteristics of
a Good Case Report
Description of the adverse events or disease experience,
including time to onset of signs or symptoms
Suspected and concomitant product therapy details (i.e.,
dose, lot number, schedule, dates, duration), including
OTC medications, dietary supplements, and recently
discontinued medications
Patient characteristics, including demographic information
(e.g., age, race, sex), baseline medical condition prior to
product therapy, comorbid conditions, use of concomitant
medications, relevant family history of disease, and
presence of other risk factors
Documentation of the diagnosis of the events, including
methods used to make the diagnosis
Clinical course of the event and patient outcomes (e.g.,
hospitalization or death)
Relevant therapeutic measures and laboratory data at
baseline, during therapy, and subsequent to therapy,
including blood levels, as appropriate
Information about response to dechallenge and rechallenge
Any other relevant information (e.g., other details relating
to the event or information on benefits received by the
patient, if important to the assessment of the event)
Source: Reference 9.
HS-16
U.S. Pharmacist April 2010 www.uspharmacist.com
3/31/10 1:44 PM
www.amgenassist.com
1-800-272-9376
For insurance
vericationprior
authorizationpatient
assistance program
informationand
billing and claims
processing support.
Amgen Assist and Amgen Inc. do not guarantee success in obtaining
reimbursement. Third party payment for medical products and services
is affected by numerous factors, not all of which can be anticipated or
resolved by our Amgen Assist staff.
2010 Amgen. All rights reserved. MC48319-A 2/10
HS-18
U.S. Pharmacist April 2010 www.uspharmacist.com
3/31/10 2:29 PM
H E A LT H S YS T E M S E D I T I O N
CONCLUSION
As a result of recent safety concerns surrounding widely
used drugs, there is an increasing focus on drug safety.
Timely, complete, and accurate ADE reporting is an essential component of monitoring, and subsequently improving,
patient safety.
The authors gratefully acknowledge Patrick DeLisle for his assistance.
References available online at www.uspharmacist.com.
HS-19
U.S. Pharmacist April 2010 www.uspharmacist.com
3/31/10 2:29 PM
H E A LT H S YS T E M S E D I T I O N
LASIK
Refractive Eye
Surgery in the
21st Century
he goal of eliminating refractive errors and allowing individuals to obtain uncorrected optimal
visual performance without glasses or contact
lenses can be successfully achieved by several surgical
procedures. This article will focus primarily on the use
of the excimer laser to reshape the cornea with a quick,
painless, and popular operation known as LASIK (laserassisted in situ keratomileusis).
3/31/10 1:45 PM
Pupil Examination: The pupil should be measured in from 110 to 180 microns. The minimum residual
both scotopic (dim) and normal (photopic) light. Mea- stromal thickness is recommended as no less than 250
surements may be obtained with infrared pupillometers microns.11
or with a simple pupil card.8 There is a possibility that
young patients with large scotopic pupils may be at Types of LASIK Surgery
higher risk for developing symptoms of glare, halos, and The patient is conscious during surgery but can be
nighttime visual disturbances following refractive surgery. given mild sedation with an oral benzodiazepine such
as diazepam. Anesthetic ophToday, with large ablation zones
thalmic drops (e.g., proparaand the use of aberrometers for
Table 1. Patient Selection
caine) are given immediately
custom ablations, this is less
Criteria
for
LASIK
before the drapes are applied
likely.
and the speculum inserted. The
Adults 18 years of age and older
Dry Eye Testing: Dryness after
patient is asked to look directly
Stable refractions
LASIK is one of the most comat a fixation target under the
Low-to-moderate
myopia
(between
-0.50
and
mon symptoms reported by
laser (patient cooperation is very
-12.00 diopters)
patients.9 It is believed to result
helpful).
Myopia with astigmatism (-5.00 diopters or less)
from the cutting of the anterior
LASIK involves photoablation
flap and the loss of cornea sen(pulses
of UV light energy) of
Low-to-moderate hyperopia without astigmatism
(<6.00
diopters)
sation that eliminates reflex
the corneal stroma after a cornea
tearing. Proper preoperative testflap has been created. The laser
Cannot have certain medical conditions, including
ing evaluating the precorneal
energy can be programmed to
autoimmune disease (e.g., lupus erythematosus,
pemphigus, rheumatoid arthritis, Sjgrens
tear film, the use of artificial
flatten the central cornea to corsyndrome,
uveitis),
uncontrolled
vascular
disease,
tears before surgery, and discusrect myopic errors (nearsightedimmunosuppression (e.g., HIV/AIDS)
sions about this common conness) or steepen the peripheral
Source: References 6, 7.
dition with the patient should
cornea to correct hyperopic
be documented. The prescription
errors (farsightedness). Traditioneye drops Restasis (cyclosporine ophthalmic emulsion ally, flaps have been produced with mechanical micro0.05%) can also be used.
keratomes, but more recently femtosecond laser technology has emerged as an alternative for flap creation.12
Topography: It is critical for all potential refractive This procedure uses ultrafast lasers (all-laser LASIK) that
surgery candidates to undergo preoperative cornea map- precisely photodisrupt tissue by using very short duraping (topography) and cornea thickness (pachymetry) tion energy pulses. The precision of this technique has
measurements to exclude patients at risk who may resulted in wide acceptance of the technology.
respond poorly to the surgery.7 Many computerized
machines are available to analyze the anterior and pos- Conventional LASIK: Conventional LASIK does not
terior curvature of the cornea to aid in selecting and use aberrometry (measurement of the imperfections in
screening good candidates for surgery. These instruments the optical system of the eye) when correcting the
map the surface of the cornea and generate data, which refractive error.13 Treatment is based upon using the
help eliminate patients with abnormal corneas such as refraction from responses obtained with a phoropter
seen in keratoconus (a thinning disorder of the cornea and recent eyeglass prescription. This corrects only
low-order aberrations known as sphere and cylinder. The
that changes it from a round shape to a cone.)
data are manually entered into the laser.
Pachymetry: Pachymetry is a measurement of the thickness of the cornea. The average cornea thickness is Wavefront-Guided LASIK: Wavefront aberrometry has
approximately 540 microns. Preoperative cornea thick- redefined the diagnosis and treatment of refractive errors
ness is an important measure used to determine the in the 21st century. This technology allows the capturstromal thickness that will result from subtracting the ing and measurement of the total optical system of the
flap thickness and the amount of tissue removed by the eye. Aberrometers using advanced polynomials are
treatment.10 It is crucial to leave behind enough corneal capable of measuring higher-order imperfections smaller
thickness to maintain cornea integrity so that the cor- than the wavelength of light and using this information
nea does not become ectatic (see Cornea Ectasia and to reduce imperfections produced by the application of
Collagen Cross-Linking). Cornea flap thickness can range the excimer laser.14
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Studies have shown that precise wavefront-guided demonstrated its potential for correction of refractive
ablation minimizes postoperative higher-order aberra- errors. Many FDA clinical trials have resulted in the
tion, resulting in better contrast sensitivity compared approval of the excimer laser to reduce or eliminate a
to conventional treatment.15 Patients theoretically have wide spectrum of refractive errors.13
Surface applications (PRK) have gained a small resurbetter nighttime vision and less chance of needing an
enhancement. This has been promoted as high-defini- gence in patients with thin corneas and in poor candidates
for LASIK who may be at risk
tion LASIK utilizing optical
for ectasia (a bulging of the corfingerprints made possible by
Table 2. Select Medications
nea). Management of postopwavefront aberrometry.
for Dry Eyes
erative pain and the application
Mechanical Keratome: In this
of the chemotherapeutic drug
OTC Medications (Products)
procedure, an automated, precimitomycin C (MMC) to prevent
Carboxyl methylcellulose artificial tears
sion gear-driven machine with
haze and scarring have added to
(Refresh Tears, TheraTears)
an oscillating blade is used to
PRKs safety and popularity.18-20
Glycerin artificial tears (Advanced Eye Relief Dry
make a thin (110-160 micron)
Eye Environmental)
Postoperative Period
superior hinged flap on the ante Hydroxypropyl methylcellulose artificial tears
(Bion Tears, GenTeal Mild)
During the early postoperative
rior surface of the cornea. This
Polyethylene glycol artificial tears (Systane,
period, patients may experience
is done once the eye is immoBlink
Tears)
significant tearing, photophobia,
bilized with a low-pressure suc Polyvinyl alcohol artificial tears (Akwa Tears,
blurred vision, and discomfort
tion ring. Complications during
Murine Tears)
because of the central corneal
translation of the keratome are
Oil-based drops (Soothe XP)
abrasion. With the use of the
uncommon but can be a major
Ophthalmologic ointments/gels (Refresh PM
bandage contact lens and nonconcern. Incomplete flaps are
Ointment, Tears Again Night & Day Gel)
steroidal anti-inflammatory drug
easily handled but prevent the
Prescription Medications
(NSAID) eye drops (e.g., dicloapplication of the laser until a
fenac sodium 0.1%, ketorolac
later time.
FreshKote Ophthalmic Solution (polyvinyl
pyrrolidone 2.0%, polyvinyl alcohol
0.4%), postoperative pain is
[87% hydrolyzed] 0.9%, polyvinyl alcohol
Femtosecond Laser (All-Laser
usually mild to moderate; how[99% hydrolyzed] 1.8%, Amisol Clear)
LASIK): More recently, femtoever, patients occasionally require
Restasis (cyclosporine ophthalmic emulsion
second laser technology (all-laser
systemic analgesia for more
0.05%)
LASIK) has emerged as an altersevere pain. The contact lens
Source: References 38-40.
native to mechanical flap creremains on the eye until the
ation.16 This method precisely
epithelial defect is healed (an
photodisrupts tissue with short-duration energy pulses average of 3-4 days). Antibiotic eye drop therapy (e.g.,
that cleave cornea tissue at a predetermined depth, tobramycin or gatifloxacin 0.3%) is usually continued
forming bubbles of water and carbon dioxide at a plane for 2 to 3 days after the defect has healed, and topical
that allows for a smooth interface once the flap is lifted.17 steroid eye drops (e.g., 1% prednisolone) may be conThere appears to be no difference between femtosecond tinued for up to 3 months postoperatively.
and microkeratome flap creation as far as visual outcomes.
However, femtosecond flaps can be made thinner and Complications
their parameters more precise than conventional meth- Intraoperative complications related to the use of the
ods. There is also an expectation of greater safety to the microkeratome occur at a rate of less than 1% in experienced hands and usually result in an incomplete or
patient than with mechanical devices.
partial primary cut.21-23 When the flap appears less than
Photorefractive Keratectomy (PRK): Laser refractive ideal, it should be replaced, and the procedure can be
surgery procedures can either be performed by intra- successfully repeated in 2 to 3 months.
stromal ablation (LASIK) or by surface ablation, generDry Eyes: There is a high incidence of the development
ally known as PRK. Both use the excimer laser.
Experimental studies evaluating the excimer laser of dry eyes after refractive surgery (up to 36.36%).24,25
with its UV light energy began in the early 1980s. In This symptom may last up to 6 months after surgery
the mid 1980s, animal and human applications per- or be permanent. A proper preoperative evaluation for
formed at Louisiana State University in New Orleans dry eyes is necessary to help prevent this postoperatively.
HS-23
U.S. Pharmacist April 2010 www.uspharmacist.com
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Pharmacologic management of dry eyes includes prescription and nonprescription medications (TABLE 2).
Another therapy is punctal occlusion, where a collagen
plug is placed in the natural drain of the eye.
of halos, starbursts, and a general reduction of qualitative vision under conditions of reduced illumination.
These are usually temporary but can persist in a small
number of cases. The use of larger optical zones and
wavefront technology has reduced the incidence of these
symptoms. Some surgeons believe there may be a relationship between the scotopic pupil diameter (size that
pupils dilate to a dark room) and nighttime visual
disturbances. Some clinicians use topical brimonidine
for night vision disturbances.
Enhancements
Enhancements are follow-up surgeries that are used to
correct residual refractive errors (i.e., over- or undercorrections) or to suit the visual needs of a patients
changing lifestyle (e.g., monovision correction, a technique that reduces the need for reading glasses or
bifocals). The timing of retreatment should be based
on a stable refraction.36
Options include recutting a flap, lifting the prior
flap, or performing PRK on top of the previous LASIK.
With increasing use of MMC for the prevention of
haze and the avoidance of epithelial ingrowth, more
surgeons are turning to PRK for enhancements.
Summary
LASIK surgery for the correction of all kinds of refractive errors offers patients a fast, safe, reproducible,
and cost-effective alternative to glasses and contact
lenses. Refinements in the delivery systems of the
excimer laser and wavefront technology have greatly
increased visual outcomes with this commonly performed procedure and have improved the quality of
life for many people.37
HS-24
U.S. Pharmacist April 2010 www.uspharmacist.com
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dextromethorphan polistirex
Bc`\=TTbVS1]cUV
Senior Care
Kaposis Sarcoma
Prognosis Varies With Form
20
U.S. Pharmacist April 2010 www.uspharmacist.com
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First-Time Generic
NEW STRENGTH
Brimonidine Tartrate
Ophthalmic Solution, 0.15%
Sterile
Characteristics of KS in Seniors
The onset of KS in the elderly is
often subtle and, as previously
mentioned, with a predisposition
to American men of Italian, Jewish, and Eastern European ancestry.4,6 Cutaneous patches and papules are violaceous and present on
the lower extremities; lesions of
the gastrointestinal tract often
require endoscopy for visualization. KS in the elderly is often
associated with diabetes mellitus
and an increased incidence of
lymphoma.6
Treatment
Lesions may return after treat-
22
U.S. Pharmacist April 2010 www.uspharmacist.com
3/31/10 1:40 PM
General Features
Prognosis
Comments
Endemic
Iatrogenic
(immunosuppressive
treatment
related)
Lymphadenopathic
Classic
pressants.4 A reduction of KS
lesions has been seen in organ
transplant patients when the
immunosuppressant dosage is
reduced; for patients who are
unable to tolerate such a reduction,
experts recommend local and systemic therapies used in the other
types of KS.4
Conclusion
Kaposis sarcoma is associated with
infection by human herpesvirus
type 8, which has been identified
in KS tissue biopsies in patients
with all forms of the disease. Pharmacists should be aware of the
clinical manifestations and course
of KS and how they differ dramat-
REFERENCES
1. Dorlands Pocket Medical Dictionary. 28th ed. Philadelphia, PA: Elsevier Saunders; 2009:743.
2. General Information About Kaposi Sarcoma. National
Cancer Institute. U.S. National Institutes of Health
[updated September 1, 2009.] www.cancer.gov/cancertopics/
pdq/treatment/kaposis/HealthProfessional/page2. Accessed
March 15, 2010.
3. Kaposis Sarcoma. MedlinePlus. National Library of Medicine. National Institutes of Health. Updated September 28,
2008. www.nlm.nih.gov/medlineplus/ency/article/000661.
htm. Accessed March 15, 2010.
4. Beers MH, Porter RS, Jones TV, et al. The Merck Manual
23
U.S. Pharmacist April 2010 www.uspharmacist.com
4/1/10 1:06 PM
TrendWatch
Severe
condition 2%
Cardiovascular
system 17%
Mental
health 29%
Auditory
system 15%
Circulatory
system 11%
Mild
condition
16%
Nonrisky
condition
11%
Cerebrovascular
system 4%
THINKSTOCK
Endocrine
system 6%
24
U.S. Pharmacist April 2010 www.uspharmacist.com
24 Trendwatch 3_30sc.indd 24
3/31/10 1:41 PM
Innovative Medicines
_ First Indian company to fully develop
an in-house biosimilar
NCEs for unmet medical needs
OTCs for a more complete selection
Dr. Reddys Laboratories, Inc. 3600 Arco Corporate Drive, Charlotte, NC 28273-7104
(866) 733-3952
www.DRREDDYS.com
DRCO / 09/09 R
Age-Related
Macular
Degeneration
Dry AMD
Dry AMD is also called geographical atrophy.1 In the
dry form, there is no abnormal vascularization in the
subretinal space, and therefore there is no exudate.2,7
Drusen deposits are clustered on the macula, and these
become larger and more numerous over time. Eventually, the RPE becomes detached and atrophies. This
results in a loss of vision due to the interference of
photoreceptor function.7 There is no treatment for
dry AMD.4
The most common symptom of dry AMD is blurred
vision, which may go away in bright light. Patients may
experience difficulty with reading or recognizing faces.
There may also be a blind spot in the middle of their
field of vision. The blind spot may be small initially,
but it can grow over time.10
Wet AMD
Wet AMD, also known as choroidal neovascularization
(CNV), is less prevalent.1,7 Only about 10% of cases
of AMD are the neovascular form; however, 80% to
TYPES OF AMD
90% of patients with severe vision loss secondary to
There are two forms of advanced AMD: dry (atrophic) AMD have neovascular AMD.9,11 The neovascular form
and wet (exudative).2 The dry form is more common, involves angiogenesis and inflammation.11 Blood vessels
but the vision loss is more severe with the wet form.9 grow from the choroid through defects in Bruchs
It is thought that inflammation may
membrane underneath the retina and
Suzanne Albrecht, PharmD, MSLIS
play an important role in both forms
pigment epithelium.2,7 These new,
Freelance Medical Writer
4,7
Woodstock, Illinois
of AMD. The late stages of AMD
immature blood vessels leak lipids
26
U.S. Pharmacist April 2010 www.uspharmacist.com
26 MacularDegen 3_26mb.indd 26
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26 REVMacularDegen 3_26mb.indd 29
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Antiangiogenic Therapy
Unlike PDT, which destroys existing CNV, antiangiogenic therapy prevents further neovascularization. 9
Angiogenesis is the formation of new blood vessels. It is
a complex process and requires interactions between
various factors, some of which are inhibitory and some
of which are stimulatory. Antiangiogenic therapy works
by either promoting inhibitory factors or blocking
stimulatory factors.9 Vascular endothelial growth factor
(VEGF) stimulates the formation of endothelial blood
vessels; it also increases the permeability of CNV and
acts as a vasodilator.11,16 There are many isoforms of
VEGF, but VEGF-A121 and VEGF-A165 are the most
prevalent in the retina.11 Moieties that inhibit VEGF
prevent the growth of these vessels.9 The three FDAapproved anti-VEGF agents used in the United States
are pegaptanib (Macugen, Eyetech), bevacizumab (Avastin, Genentech), and ranibizumab (Lucentis, Genentech).
30
U.S. Pharmacist April 2010 www.uspharmacist.com
26 MacularDegen 3_26mb.indd 30
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MSM
TM
2010, J M SMITH CORPORATION. QS/1 is a registered trademark and MSM is a trademark of the J M Smith Corporation.
1-800-231-7776
www.qs1.com
32
U.S. Pharmacist April 2010 www.uspharmacist.com
26 MacularDegen 3_26mb.indd 32
3/31/10 1:41 PM
Want
Fast
pro
p
rotec
tected
ted
ed cells
cceells
lls
protected
#1 pharmacist recommended.
3,4
Early treatment with Abreva ensures best results. If a cold sore lasts for more than 10 days, you should
encourage your patient to see their physician.
* Based on laboratory studies (1) Sacks SL et al. Clinical efcacy of topical docosanol 10% cream for
herpes simplex labialis: a multicenter, randomized, placebo-controlled trial. J Am Acad Dermatol. 2001;
45:222-230. (2) Pope LE et al. Anti-herpes simplex virus activity of n-docosanol correlates with intracellular
metabolic conversion of the drug. Jnl Lipid Research V27, Issue 10, 1996: 2167-2178. (3) Pharmacy
Times OTC Recommendation Survey 2009 (4) Pharmacy Today Annual OTC Product Survey 2010
26 MacularDegen 3_26mb.indd 33
2010 GlaxoSmithKline
Consumer Healthcare
3/31/10 1:41 PM
Treatment
Options for
Dry Eye
Disease
THINKSTOCK
Symptoms
Patients with DED typically experience ocular discomfort,
photosensitivity, and blurry vision. Ocular discomfort is
described as a dry, scratchy, gritty, or sandy feeling, as
well as foreign body sensations, irritation, soreness or
pain, burning, itching, and ocular fatigue. Patients may
also complain about mucous discharge, contact lens
intolerance, and red eyes. Initially, patients may present
with excessive tearing due to corneal irritation, causing
reflex tearing.6,7 The onset of symptoms is usually gradual, bilateral, and chronic; symptoms typically become
more bothersome later in the day and are intensified by
various environmental factors (TABLE 1).6
Etiology
The DEWS recommendations classified the etiology of Diagnosis
DED into two categories: aqueous tear-deficient and DED may be diagnosed by an eye care professional,
although the diagnosis may be challenging due to the
evaporative.4
Aqueous tear-deficient dry eye is due to decreased lack of uniform criteria.6,8,9
A combination of tests, both subjective and objective,
volume and production of tears. This may be caused by
Sjgrens syndrome or stem from non-Sjgrens causes. are used in the evaluation of DED. Objective clinical
Sjgrens syndrome, an autoimmune disease, attacks the measures include assessing tear film instability, ocular
lacrimal and salivary glands, leading to dry mouth and surface damage, and aqueous tear flow.6,8,10 Tear osmolardry eyes. Non-Sjgrens dry eye is caused by lacrimal ity measurement has been suggested to be highly diagnostic for dry eye, as it is testing for
dysfunctions, including lacrimal defiEmily M. Ambizas, PharmD, CGP
a factor that is directly related to the
ciencies, obstruction of the lacrimal
Associate Clinical Professor
gland ducts, and reflex hyposecretion.4 St. Johns University, College of Pharmacy & cause.8,10 Questionnaires are used to
Allied Health Professions
determine the severity of symptoms,
Evaporative dry eye is due to
Queens, New York
effect on daily activities, and impact
increased tear evaporation in the presClinical Specialist, Rite Aid Pharmacy
Whitestone, New York
on quality of life. However, questionence of normal lacrimal secretion. The
naires should never be used alone when
cause of this may be described as intrinPriti N. Patel, PharmD, BCPS
Assistant Clinical Professor
diagnosing DED and should always
sic or extrinsic. Intrinsic causes include
Director, Drug Information Center
be used in combination with objective
meibomian gland dysfunction (the
St. Johns University, College of Pharmacy &
data collected through the use of diagmost common cause of evaporative
Allied Health Professions
Queens, New York
nostic tests.
dry eye), eyelid aperture disorders or
34
U.S. Pharmacist April 2010 www.uspharmacist.com
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Treatment Options
The goals of treatment for DED are to reduce ocular
discomfort, improve quality of life, and return the ocular surface and tear film to their normal states, preventing further damage to the ocular tissue and cornea.
Treatment approaches vary; there are many nonpharmacologic and pharmacologic therapies to choose from.11
Ultimately, the underlying cause should be identified
and corrected. The mainstay of treatment is to lubricate
the eye with artificial tear supplements.1,12
Nonpharmacologic Treatment: Educating patients about
36
U.S. Pharmacist April 2010 www.uspharmacist.com
3/31/10 1:42 PM
Lubricating Agents
Preservatives
No preservative
Glycerin 1%
No preservative
No preservative
GenAquaa
GenTeal Mild
HPMC 0.2%
GenAquaa
GenTeal PM
No preservative
Hypotears
Benzalkonium chloride
Refresh Celluvisc
CMC 1%
No preservative
Refresh Classic
No preservative
No preservative
Refresh Liquigel
CMC 1%
Puriteb
Refresh Optive
Puriteb,c
Refresh PM
Soothe XP
Systane
Polyquadc,d
Polyquadd 0.001%
Tears Naturale PM
No preservative
Polyquadc,d 0.001%
Tears Renewed
TheraTears (bottle)
CMC 0.25%
Sodium perboratec
Benzalkonium chloridec
Benzalkonium chloride
GenAqua: sodium perborate. b Purite: sodium chlorite. c Also available preservative free. d Polyquad: polyquaternium. CMC: carboxymethylcellulose;
EDTA: ethylenediaminetetraacetic acid; HPMC: hydroxypropyl methylcellulose; PHMB: polyhexamethylene biguanide; PVA: polyvinyl alcohol.
Source: References 21, 22.
37
U.S. Pharmacist April 2010 www.uspharmacist.com
3/31/10 1:42 PM
Humalog KwikPen, part of the Humalog approach, is designed to help t mealtime therapy into
your patients life. Its small, doesnt need refrigeration after the rst use, and can be used almost
anywhere. To nd out more, go to www.Humalog.com or see your Lilly sales representative.
Humalog is for use in patients with diabetes mellitus for the control
of hyperglycemia. Hypoglycemia is the most common adverse effect
associated with insulins, including Humalog.
For complete safety prole, please see Important Safety Information
and Brief Summary of full Prescribing Information on adjacent pages.
Please see full user manual that accompanies the pen.
Indication
Humalog (insulin lispro injection [rDNA origin]) is for use in patients with diabetes mellitus for the control of
hyperglycemia. Humalog should be used with longer-acting insulin, except when used in combination with sulfonylureas
in patients with type 2 diabetes.
Hypoglycemia
Hypoglycemia is the most common adverse effect associated with insulins, including Humalog. Hypoglycemia
can happen suddenly, and symptoms may be different for each person and may change from time to time.
Severe hypoglycemia can cause seizures and may be life-threatening.
HI62001
HUMALOG
INSULIN LISPRO INJECTION (rDNA ORIGIN)
BRIEF SUMMARY: Consult package insert for complete prescribing information.
INDICATIONS AND USAGE: Humalog is an insulin analog that is indicated in the treatment of patients with
diabetes mellitus for the control of hyperglycemia. Humalog has a more rapid onset and a shorter duration of
action than regular human insulin. Therefore, in patients with type 1 diabetes, Humalog should be used in
regimens that include a longer-acting insulin. However, in patients with type 2 diabetes, Humalog may be used
without a longer-acting insulin when used in combination therapy with sulfonylurea agents.
Humalog may be used in an external insulin pump, but should not be diluted or mixed with any other
insulin when used in the pump. Humalog administration in insulin pumps has not been studied in patients
with type 2 diabetes.
CONTRAINDICATIONS: Humalog is contraindicated during episodes of hypoglycemia and in patients sensitive to
Humalog or any of its excipients.
WARNINGS: This human insulin analog differs from regular human insulin by its rapid onset of action as well
as a shorter duration of activity. When used as a mealtime insulin, the dose of Humalog should be given
within 15 minutes before or immediately after the meal. Because of the short duration of action of Humalog,
patients with type 1 diabetes also require a longer-acting insulin to maintain glucose control (except when
using an external insulin pump).
External Insulin Pumps: When used in an external insulin pump, Humalog should not be diluted or mixed
with any other insulin. Patients should carefully read and follow the external insulin pump manufacturers
instructions and the PATIENT INFORMATION leaet before using Humalog.
Physicians should carefully evaluate information on external insulin pump use in the Humalog physician
package insert and in the external insulin pump manufacturers instructions. If unexplained hyperglycemia or
ketosis occurs during external insulin pump use, prompt identication and correction of the cause is necessary.
The patient may require interim therapy with subcutaneous insulin injections (see PRECAUTIONS, For Patients
Using External Insulin Pumps, and DOSAGE AND ADMINISTRATION).
Hypoglycemia is the most common adverse effect associated with the use of insulins, including Humalog.
As with all insulins, the timing of hypoglycemia may differ among various insulin formulations. Glucose
monitoring is recommended for all patients with diabetes and is particularly important for patients using an
external insulin pump.
Any change of insulin should be made cautiously and only under medical supervision. Changes in insulin
strength, manufacturer, type (eg, regular, NPH, analog), species, or method of manufacture may result in the
need for a change in dosage.
PRECAUTIONS: GeneralHypoglycemia and hypokalemia are among the potential clinical adverse effects
associated with the use of all insulins. Because of differences in the action of Humalog and other insulins, care
should be taken in patients in whom such potential side effects might be clinically relevant (eg, patients who are
fasting, have autonomic neuropathy, or are using potassium-lowering drugs or patients taking drugs sensitive to
serum potassium level). Lipodystrophy and hypersensitivity are among other potential clinical adverse effects
associated with the use of all insulins.
As with all insulin preparations, the time course of Humalog action may vary in different individuals or at
different times in the same individual and is dependent on site of injection, blood supply, temperature, and
physical activity.
Adjustment of dosage of any insulin may be necessary if patients change their physical activity or their usual
meal plan. Insulin requirements may be altered during illness, emotional disturbances, or other stress.
HypoglycemiaAs with all insulin preparations, hypoglycemic reactions may be associated with the
administration of Humalog. Rapid changes in serum glucose concentrations may induce symptoms of
hypoglycemia in persons with diabetes, regardless of the glucose value. Early warning symptoms of
hypoglycemia may be different or less pronounced under certain conditions, such as long duration of diabetes,
diabetic nerve disease, use of medications such as beta-blockers, or intensied diabetes control.
Renal ImpairmentThe requirements for insulin may be reduced in patients with renal impairment.
Hepatic ImpairmentAlthough impaired hepatic function does not affect the absorption or disposition of
Humalog, careful glucose monitoring and dose adjustments of insulin, including Humalog, may be necessary.
AllergyLocal AllergyAs with any insulin therapy, patients may experience redness, swelling, or itching
at the site of injection. These minor reactions usually resolve in a few days to a few weeks. In some instances,
these reactions may be related to factors other than insulin, such as irritants in a skin cleansing agent or poor
injection technique.
Systemic AllergyLess common, but potentially more serious, is generalized allergy to insulin, which may
cause rash (including pruritus) over the whole body, shortness of breath, wheezing, reduction in blood pressure,
rapid pulse, or sweating. Severe cases of generalized allergy, including anaphylactic reaction, may be lifethreatening. Localized reactions and generalized myalgias have been reported with the use of cresol as an
injectable excipient. In Humalog-controlled clinical trials, pruritus (with or without rash) was seen in 17 patients
receiving Humulin R (N=2969) and 30 patients receiving Humalog (N=2944) (P=.053).
Antibody ProductionIn large clinical trials, antibodies that cross-react with human insulin and insulin lispro
were observed in both Humulin R- and Humalog-treatment groups. As expected, the largest increase in the
antibody levels during the 12-month clinical trials was observed with patients new to insulin therapy.
Usage of Humalog in External Insulin PumpsThe infusion set (reservoir syringe, tubing, and catheter),
Disetronic D-TRON2,3 or D-TRONplus2,3 cartridge adapter, and Humalog in the external insulin pump
reservoir should be replaced and a new infusion site selected every 48 hours or less. Humalog in the external
insulin pump should not be exposed to temperatures above 37C (98.6F).
In the D-TRON 2,3 or D-TRONplus 2,3 pump, Humalog 3 mL cartridges may be used for up to 7 days. However,
as with other external insulin pumps, the infusion set should be replaced and a new infusion site should be
selected every 48 hours or less.
When used in an external insulin pump, Humalog should not be diluted or mixed with any other insulin (see
INDICATIONS AND USAGE, WARNINGS, PRECAUTIONS, For Patients Using External Insulin Pumps, Mixing of
Insulins, DOSAGE AND ADMINISTRATION, and Storage).
Information for PatientsPatients should be informed of the potential risks and advantages of Humalog and
alternative therapies. Patients should also be informed about the importance of proper insulin storage, injection
technique, timing of dosage, adherence to meal planning, regular physical activity, regular blood glucose
monitoring, periodic hemoglobin A1C testing, recognition and management of hypoglycemia and hyperglycemia,
and periodic assessment for diabetes complications.
Patients should be advised to inform their physician if they are pregnant or intend to become pregnant.
Refer patients to the PATIENT INFORMATION leaet for timing of Humalog dosing (<
_15 minutes before or
immediately after a meal), storing insulin, and common adverse effects.
For Patients Using Insulin Pen Delivery Devices: Before starting therapy, patients should read the PATIENT
INFORMATION leaet that accompanies the drug product and the User Manual that accompanies the delivery
device. They should also reread these materials each time the prescription is renewed. Patients should be
instructed on how to properly use the delivery device, prime the Pen to a stream of insulin, and properly dispose
of needles. Patients should be advised not to share their Pens with others.
For Patients Using External Insulin Pumps: Patients using an external infusion pump should be trained in
intensive insulin therapy and in the function of their external insulin pump and pump accessories. Humalog was
tested in the MiniMed1 Models 506, 507, and 508 insulin pumps using MiniMed1 Polyn1 infusion sets.
Humalog was also tested in the Disetronic 2 H-TRONplus V100 insulin pump (with plastic 3.15 mL insulin
reservoir), and the Disetronic D-TRON 2,3 and D-TRONplus 2,3 insulin pumps (with Humalog 3 mL cartridges)
using Disetronic Rapid2 infusion sets.
The infusion set (reservoir syringe, tubing, catheter), D-TRON2,3 or D-TRONplus 2,3 cartridge adapter,
and Humalog in the external insulin pump reservoir should be replaced, and a new infusion site selected
every 48 hours or less. Humalog in the external pump should not be exposed to temperatures above
37C (98.6F).
A Humalog 3 mL cartridge used in the D-TRON 2,3 or D-TRONplus 2,3 pump should be discarded after 7 days,
even if it still contains Humalog. Infusion sites that are erythematous, pruritic, or thickened should be reported to
medical personnel, and a new site selected.
Humalog should not be diluted or mixed with any other insulin when used in an external insulin pump.
Laboratory TestsAs with all insulins, the therapeutic response to Humalog should be monitored by periodic
blood glucose tests. Periodic measurement of hemoglobin A1C is recommended for the monitoring of long-term
glycemic control.
Drug InteractionsInsulin requirements may be increased by medications with hyperglycemic activity, such
as corticosteroids, isoniazid, certain lipid-lowering drugs (eg, niacin), estrogens, oral contraceptives,
phenothiazines, and thyroid replacement therapy (see CLINICAL PHARMACOLOGY).
Insulin requirements may be decreased in the presence of drugs that increase insulin sensitivity or have
hypoglycemic activity, such as oral antidiabetic agents, salicylates, sulfa antibiotics, certain antidepressants
(monoamine oxidase inhibitors), angiotensin-converting-enzyme inhibitors, angiotensin II receptor blocking
agents, beta-adrenergic blockers, inhibitors of pancreatic function (eg, octreotide), and alcohol. Beta-adrenergic
blockers may mask the symptoms of hypoglycemia in some patients.
Mixing of InsulinsCare should be taken when mixing all insulins as a change in peak action may occur.
The American Diabetes Association warns in its Position Statement on Insulin Administration, On mixing,
physiochemical changes in the mixture may occur (either immediately or over time). As a result, the physiological
response to the insulin mixture may differ from that of the injection of the insulins separately. Mixing Humalog
with Humulin N or Humulin U does not decrease the absorption rate or the total bioavailability of Humalog.
Given alone or mixed with Humulin N, Humalog results in a more rapid absorption and glucose-lowering effect
compared with regular human insulin.
PregnancyTeratogenic EffectsPregnancy Category BReproduction studies with insulin lispro have
been performed in pregnant rats and rabbits at parenteral doses up to 4 and 0.3 times, respectively, the average
human dose (40 units/day) based on body surface area. The results have revealed no evidence of impaired
fertility or harm to the fetus due to Humalog. There are, however, no adequate and well-controlled studies with
Humalog in pregnant women. Because animal reproduction studies are not always predictive of human response,
this drug should be used during pregnancy only if clearly needed.
Although there are limited clinical studies of the use of Humalog in pregnancy, published studies with human
insulins suggest that optimizing overall glycemic control, including postprandial control, before conception and
during pregnancy improves fetal outcome. Although the fetal complications of maternal hyperglycemia have been
well documented, fetal toxicity also has been reported with maternal hypoglycemia. Insulin requirements usually
fall during the rst trimester and increase during the second and third trimesters. Careful monitoring of the
patient is required throughout pregnancy. During the perinatal period, careful monitoring of infants born to
mothers with diabetes is warranted.
Nursing MothersIt is unknown whether Humalog is excreted in signicant amounts in human milk. Many
drugs, including human insulin, are excreted in human milk. For this reason, caution should be exercised when
Humalog is administered to a nursing woman. Patients with diabetes who are lactating may require adjustments
in Humalog dose, meal plan, or both.
Pediatric UseIn a 9-month, crossover study of prepubescent children (n=60), aged 3 to 11 years,
comparable glycemic control as measured by A1C was achieved regardless of treatment group: regular human
insulin 30 minutes before meals 8.4%, Humalog immediately before meals 8.4%, and Humalog immediately
after meals 8.5%. In an 8-month, crossover study of adolescents (n=463), aged 9 to 19 years, comparable
glycemic control as measured by A1C was achieved regardless of treatment group: regular human insulin 30 to
45 minutes before meals 8.7% and Humalog immediately before meals 8.7%. The incidence of hypoglycemia
was similar for all 3 treatment regimens. Adjustment of basal insulin may be required. To improve accuracy in
dosing in pediatric patients, a diluent may be used. If the diluent is added directly to the Humalog vial, the shelf
life may be reduced (see DOSAGE AND ADMINISTRATION).
Geriatric UseOf the total number of subjects (n=2834) in 8 clinical studies of Humalog, 12% (n=338) were
65 years of age or over. The majority of these were patients with type 2 diabetes. A1C values and hypoglycemia
rates did not differ by age. Pharmacokinetic/pharmacodynamic studies to assess the effect of age on the onset
of Humalog action have not been performed.
ADVERSE REACTIONS: Clinical studies comparing Humalog with regular human insulin did not demonstrate a
difference in frequency of adverse events between the 2 treatments.
Adverse events commonly associated with human insulin therapy include the following:
Body as a Wholeallergic reactions (see PRECAUTIONS).
Skin and Appendagesinjection site reaction, lipodystrophy, pruritus, rash.
Otherhypoglycemia (see WARNINGS and PRECAUTIONS).
OVERDOSAGE: Hypoglycemia may occur as a result of an excess of insulin relative to food intake, energy
expenditure, or both. Mild episodes of hypoglycemia usually can be treated with oral glucose. Adjustments in
drug dosage, meal patterns, or exercise may be needed. More severe episodes with coma, seizure, or neurologic
impairment may be treated with intramuscular/subcutaneous glucagon or concentrated intravenous glucose.
Sustained carbohydrate intake and observation may be necessary because hypoglycemia may recur after
apparent clinical recovery.
DOSAGE AND ADMINISTRATION: Humalog is intended for subcutaneous administration, including use in select
external insulin pumps (see DOSAGE AND ADMINISTRATION, External Insulin Pumps). Dosage regimens of
Humalog will vary among patients and should be determined by the healthcare provider familiar with the
patients metabolic needs, eating habits, and other lifestyle variables. Pharmacokinetic and pharmacodynamic
studies showed Humalog to be equipotent to regular human insulin (ie, one unit of Humalog has the same
glucose-lowering effect as one unit of regular human insulin), but with more rapid activity. The quicker glucoselowering effect of Humalog is related to the more rapid absorption rate from subcutaneous tissue. An adjustment
of dose or schedule of basal insulin may be needed when a patient changes from other insulins to Humalog,
particularly to prevent premeal hyperglycemia.
When used as a mealtime insulin, Humalog should be given within 15 minutes before or immediately after a
meal. Regular human insulin is best given 30 to 60 minutes before a meal. To achieve optimal glucose control,
the amount of longer-acting insulin being given may need to be adjusted when using Humalog.
The rate of insulin absorption and consequently the onset of activity are known to be affected by the site of
injection, exercise, and other variables. Humalog was absorbed at a consistently faster rate than regular human
insulin in healthy male volunteers given 0.2 U/kg regular human insulin or Humalog at abdominal, deltoid, or
femoral sites, the 3 sites often used by patients with diabetes. When not mixed in the same syringe with other
insulins, Humalog maintains its rapid onset of action and has less variability in its onset of action among injection
sites compared with regular human insulin (see PRECAUTIONS). After abdominal administration, Humalog
concentrations are higher than those following deltoid or thigh injections. Also, the duration of action of Humalog
is slightly shorter following abdominal injection, compared with deltoid and femoral injections. As with all insulin
preparations, the time course of action of Humalog may vary considerably in different individuals or within the
same individual. Patients must be educated to use proper injection techniques.
Humalog in a vial may be diluted with STERILE DILUENT for Humalog, Humulin N, Humulin R, Humulin 70/30,
and Humulin R U-500 to a concentration of 1:10 (equivalent to U-10) or 1:2 (equivalent to U-50). Diluted
Humalog may remain in patient use for 28 days when stored at 5C (41F) and for 14 days when stored at 30C
(86F). Do not dilute Humalog contained in a cartridge or Humalog used in an external insulin pump.
Parenteral drug products should be inspected visually before use whenever the solution and the container
permit. If the solution is cloudy, contains particulate matter, is thickened, or is discolored, the contents must not
be injected. Humalog should not be used after its expiration date. The cartridge containing Humalog is not
designed to allow any other insulin to be mixed in the cartridge or for the cartridge to be relled with insulin.
External Insulin PumpsHumalog was tested in MiniMed1 Models 506, 507, and 508 insulin pumps using
MiniMed1 Polyn1 infusion sets. Humalog was also tested in the Disetronic 2 H-TRONplus V100 insulin
pump (with plastic 3.15 mL insulin reservoir) and the Disetronic D-TRON 2,3 and D-TRONplus 2,3 pumps (with
Humalog 3 mL cartridges) using Disetronic Rapid2 infusion sets. Humalog should not be diluted or mixed with
any other insulin when used in an external insulin pump.
HOW SUPPLIED:
Humalog (insulin lispro injection, USP [rDNA origin]) is available in the following package sizes (with each
presentation containing 100 units insulin lispro per mL [U-100]):
10 mL vials
NDC 0002-7510-01 (VL-7510)
3 mL vials
NDC 0002-7510-17 (VL-7533)
NDC 0002-7516-59 (VL-7516)
5 x 3 mL cartridges3
5 x 3 mL prelled insulin delivery devices (Pen)
NDC 0002-8725-59 (HP-8725)
Storage Unopened Humalog should be stored in a refrigerator (2 to 8C [36 to 46F]), but not in the
freezer. Do not use Humalog if it has been frozen. Unrefrigerated (below 30C [86F]) 12 vials, cartridges, Pens,
and KwikPens must be used within 28 days or be discarded, even if they still contain Humalog. Protect from
direct heat and light.
Use in an External Insulin PumpA Humalog 3mL cartridge used in the D-TRON2,3 or D-TRONplus2,3
should be discarded after 7 days, even if it still contains Humalog. Infusion sets, D-TRON 2,3 and D-TRONplus 2,3
cartridge adapters, and Humalog in the external insulin pump reservoir should be discarded every 48 hours
or less.
Literature revised December 7, 2009
KwikPens manufactured by Eli Lilly and Company, Indianapolis, IN 46285, USA.
Pens manufactured by Eli Lilly and Company, Indianapolis, IN 46285, USA or Lilly France,
F-67640 Fegersheim, France.
Vials manufactured by Eli Lilly and Company, Indianapolis, IN 46285, USA or Hospira, Inc.,
Lake Forest, IL 60045, USA or Lilly France, F-67640 Fegersheim, France.
Cartridges manufactured by Lilly France, F-67640 Fegersheim, France for Eli Lilly and Company,
Indianapolis, IN 46285, USA.
www.humalog.com
Copyright 1996, 2008, Eli Lilly and Company. All rights reserved.
mentation with omega-3 fatty acids decreases the likelihood of a woman experiencing dry eye.16 Supplementation with omega-3 fatty acids has also been shown to be
useful in the treatment of dry eye. Omega-3 fatty acids
can help restore the lipid layer of tear film, decrease
inflammation, and increase tear production.13,17
Other Treatments: If the OTC and prescription products
Helping Patients
Depending on the severity of the patients case, a pharmacist may recommend a variety of products. Patients suffering from mild DED will have episodic occurrences usually
due to environmental stress. Severe DED is seen in those
patients who persistently experience symptoms, which can
be disabling, and may have possible damage to the ocular
surface.1,4 For mild cases of DED, using an artificial tear
product 1 to 2 times a day is recommended. For more
severe cases, pharmacists can recommend a product to be
used 3 to 4 times daily.18 When recommending a product,
pharmacists should remember that patients who use eye
drops for dry eye frequently throughout the day would
benefit from formulations that are either preservative free
or include the less irritating preservatives polyquaternium-1,
sodium chlorite, and sodium perborate.
Artificial tear preparations with higher viscosity tend
to have longer-lasting effects, as the products stay on the
eye for a longer period of time. These products, however,
also cause buildup around the eye, and for cosmetic
Conclusion
Dry eye disease is a common disorder experienced by
many people, and it is a frequent cause of patient visits
to pharmacies for OTC treatments. Pharmacists should
be familiar with the various products available in order
to assist patients in choosing an appropriate product.
References available online at www.uspharmacist.com.
41
U.S. Pharmacist April 2010 www.uspharmacist.com
3/31/10 1:42 PM
THINKSTOCK
3/31/10 1:42 PM
com102632a.indd 1
1/20/10 8:09 PM
Is
your
vision
affected?
using prescription medications;
istered 5-8 times per day) and
Do you know what the problem could be?
therefore, patients should be
200 to 400 mg of oral acyclovir
Is there an obvious cause?
referred to their physician.
administered 5 times daily are
Have you been using a computer for
available by prescription. Other
prolonged periods of time?
Blepharitis
options include acyclovir ophSource: Reference 1.
Chronic inflammation of the
thalmic ointment, oral valacyeyelids causes a condition known
clovir (500 mg 2-3 times daily),
as blepharitis. Patients commonly complain of an itchy, and oral famciclovir (250 mg twice daily). Since topgritty, uncomfortable red eye that is worse upon waking. ical antivirals can cause toxicity if used for more than
It is not uncommon to see dandrufflike scaling on 2 weeks, they are generally avoided. Similarly, topical
eyelashes, missing or misdirected eyelashes, and swollen steroids are not recommended since they can worsen
eyelids.5,6 Patients should be advised that they should the infection.8
wash the eyelids with diluted baby shampoo or eye
scrub solution. Gentle lid massages and warm compresses Marginal Keratitis
will also provide some relief. While patients should Marginal keratitis is an inflammation of the cornea
experience relief within one month, this treatment characterized by reduced vision, a painful red eye,
should be continued indefinitely. If this fails, however, sensitivity to light, foreign body sensation, and a mucoa prescription ophthalmic antibiotic may be required.5,6 purulent discharge. It is a common, transient, usually
Oral antibiotics and topical steroids may be required unilateral condition that may be associated with chronic
in severe cases.
staphylococcal blepharitis.7 Patients presenting with the
above listed symptoms should be referred to an ophEpiscleritis
thalmologist for a diagnosis. Marginal keratitis can be
The episclera is the layer found under the conjunctiva, successfully treated using topical steroids.1
covering the white of the eye. Inflammation of this
layer presents as redness as a result of dilation of the Subconjunctival Hemorrhage
blood vessels that are found in this layer. This maybe A subconjunctival hemorrhage is characterized by red,
sectoral whereby only one part is affected, or diffuse, flat discoloration due to bleeding from the small blood
in which case most of the episclera is inflamed. Episcle- vessels that run through the conjunctiva. The most
ritis is commonly self-limiting and resolves itself within common cause for spontaneous subconjunctival hemor3 weeks. In rare cases, episcleritis has been associated rhage is idiopathic in nature; the condition is painless,
with rheumatoid arthritis. Patients with recurring clearing itself within 7 to 14 days. In a few cases, the
episodes should be referred to an ophthalmologist. redness may be associated with bleeding disorders, the
Topical NSAIDs and topical steroids may be prescribed use of anticoagulants, conjunctivitis, scleritis, or trauma
to the eye. Warm compresses may be useful in sympfor severe cases.5,6
should be referred to their physician for further investigation. Prescription medications for allergic conjunctivitis include mast-cell stabilizing agents such as sodium
cromolyn and nedocromil, as well as anti-inflammatory
agents and topical nonsteroidal anti-inflammatory drugs
(NSAIDs), namely ketorolac.5
44
U.S. Pharmacist April 2010 www.uspharmacist.com
3/31/10 1:42 PM
Uveitis
Uveitis or iritis is an inflammation of the iris, the ciliary body, or the choroid. Iritis may result in pain that
radiates to the brow and temple; it develops with time
along with redness in the eye. Other symptoms of
iritis include watering, red eye, blurred vision, and
photophobia. Iritis should be referred for further investigation. Patients are commonly treated with steroid
eye drops to alleviate the pain and inflammation.6
Arcus Senilis
Arcus senilis (corneal arcus) is a bilateral condition
manifesting as a white ring in the periphery of the
cornea.7 It is a lipid-rich corneal deposit that does not
affect the patients vision. It begins at the top and bottom of the cornea and spreads to form a complete ring.
It is most commonly seen in elderly patients. Therefore,
arcus senilis in patients below 50 years of age should
be referred for a lipid profile, since it may indicate
hyperlipidemia, hypercholesterolemia, or hyperlipoproteinemia.8 However, the relationship between arcus
senilis and cardiovascular disease is yet to be established.9
Dry Eye Syndrome
Dry eye syndrome, due to decreased production of tears
or excessive tear evaporation, causes discomfort and
soreness. Patients may also complain about a foreign
body sensation in the eye(s). Underlying causes of dry
eye include Sjgrens syndrome, aging, staring at a
computer screen for too long, blinking problems, and
environmental factors. Additionally, patients taking
such medications as oral contraceptives, antihistamines,
and beta-blockers may experience dry eyes. Pharmacists
are in an ideal position to discover this adverse reaction.
Dry eye syndrome can be managed using nonprescription artificial tear products (e.g., Murine Tears
Dry Eyes, Visine Tears Dry Eye Relief ).10 Many OTC
products are available, and preservative-free formulations are recommended if the patient experiences
itching and irritation with the drops (e.g., Bion Tears,
Refresh Celluvisc).10 Dryness can also be prevented by
the use of humidifiers. Cyclosporine eye drops that
increase tear production are available by prescription
(e.g., Restasis).5
Floaters
Patients describe floaters as dark specks or cobwebs that
are seen in the field of vision. They are shadows of the
fibers that clump together in the vitreous gel. While
45
U.S. Pharmacist April 2010 www.uspharmacist.com
3/31/10 1:42 PM
Trichiasis
Trichiasis is a condition whereby the eyelashes grow Preservatives in Eye Care Products
inwards, causing corneal abrasion and thus affecting Additives, such as preservatives, need to be taken into
the eyesight. The eyelash needs to be regularly pulled consideration when selecting an appropriate medication.
out with a tweezer by a qualified health care profes- Preservatives in eye drops can cause stinging and itching as well as keratitis.13 Fursional, and sometimes electrolythermore, preservatives decrease
sis or cryotherapy of the hair
the stability of the precorneal
follicles may be considered.
Table 2. Symptoms That
tear film and have a detergent
Require Immediate Referral
Watery Eyes
effect on the lipid layer, worsen Pain in the eyes
Watery eyes are caused by excesing a dry eye. 14 Preservatives,
Blurred or distorted vision
Worsening symptoms
sive tear production, a natural
such as benzalkonium chloride,
Any doubt about the diagnosis
process that keeps the eye lubriare taken up by contact lenses,
No improvement with any OTC medications
cated and clean. Allergies are a
particularly soft contact lenses.
previously used (after 7 days)
common cause of watery eyes,
The accumulation of such preSource: Reference 1.
in addition to blepharitis and
servatives eventually reaches toxic
infection. The choice of treatlevels, causing further irritation
ment will be based upon the cause. Nonprescription to the eye. Patients should be advised not to wear any
antihistamines may be useful in preventing watery eyes lenses for an hour after instilling eye drops containing
related to allergies.
preservatives.15
Xanthelasma
Xanthelasma is a frequently bilateral condition that is
usually found in elderly individuals and those with
hypercholesterolemia. It presents as a yellow subcutaneous plaque on the eyelids. Since it can be an indication
of hypercholesterolemia, patients should be referred for
a cholesterol test.7
Foreign Body in the Eye
The symptoms of a foreign body include sharp pain,
burning, irritation, tearing, and redness. The patient
may feel something in the eye when moving the eye
around while it is closed and a scratching sensation
upon blinking. Bleeding may be seen in the white part
of the eye, and in more severe cases the vision may be
REFERENCES
1. Elton M. Ocular conditions from A to Z (ii). Pharm J. 2007;278:255-258.
2. Berdy GJ, Berdy SS. Ocular allergic disorders: disease entities and differential
diagnoses. Curr Allergy Asthma Rep. 2009;9:297-303.
3. Bielory L, Lien KW, Bigelsen S. Efficacy and tolerability of newer antihistamines
in the treatment of allergic conjunctivitis. Drugs. 2005;65:215-228.
4. Terrie YC. A pharmacists guide to OTC therapy: ophthalmic products.
Pharmacy Times. May 1, 2005. www.pharmacytimes.com/issue/pharmacy/2005/
2005-05/2005-05-9515. Accessed February 2, 2010.
5. Cronau H, Kankanla RR, Mauger T. Diagnosis and management of red eye in
primary care. Am Fam Physician. 2010;81:137-144.
6. Elton M. Ocular conditions from A to Z (i). Pharm J. 2007;278:195-198.
7. Kanski JJ, Nischal KK. Ophthalmology: Clinical Signs and Differential Diagnosis.
London, UK: Mosby; 1999.
8. American Academy of Ophthalmology Cornea/External Disease Panel. Preferred
Practice Pattern Guidelines. Conjunctivitis. San Francisco, CA: American Academy
of Ophthalmology; 2008. www.aao.org/ppp. Accessed March 4, 2010.
46
U.S. Pharmacist April 2010 www.uspharmacist.com
3/31/10 1:42 PM
PharmQD.com
Contemporary Compounding
FORMULA
Estradiol 0.1 mg/g Vaginal Solution
Rx (for 100 g):
Ingredient
Estradiol
Pluronic P105
Propylene glycol
Purified water
light-resistant containers.
Labeling: Keep out of the reach
of children. For vaginal use.
Loyd V. Allen, Jr, PhD
Professor Emeritus, College of Pharmacy,
University of Oklahoma, Oklahoma City
10 mg
45 g
48 g
7g
48
U.S. Pharmacist April 2010 www.uspharmacist.com
48 Compounding 3_30sc.indd 48
3/31/10 1:42 PM
Contemporary Compounding
REFERENCES
1. USP Pharmacists Pharmacopeia. 2nd ed.
Rockville, MD: US Pharmacopeial Convention, Inc; 2008:775-779.
2. Allen LV Jr. Standard operating procedure
for performing physical quality assessment of
oral and topical liquids. IJPC. 1999;3:
146-147.
3. McEvoy GK. AHFS 2010 Drug Information. Bethesda, MD: American Society of
Health-System Pharmacists; 2010:3131-3136.
4. Collett JH. Poloxamer. In: Rowe RC, Sheskey PJ, Quinn ME, eds. Handbook of Pharmaceutical Excipients. 6th ed. London, England:
Pharmaceutical Press; 2009:506-509.
5. Weller PJ. Propylene glycol. In: Rowe RC,
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48 Compounding 3_30sc.indd 49
3/31/10 1:42 PM
Generic Trends
Hospira Completes
Acquisition of Orchid
Hospira finalized its $400 million
acquisition of the generic injectables business of Orchid Chemicals
& Pharmaceuticals. The deal
includes Orchids beta-lactam antibiotic formulations operations,
encompassing its penicillin, cephalosporin, and carbapenem facilities,
and an R&D site. We are excited
to acquire new capabilities that will
create opportunities for commercial
growth, position us strongly in a
key antibiotics area, expand out
global footprint, and enhance our
ability to provide lower cost, highquality products to patients, said
Hospira COO Terry Kearney.
50
U.S. Pharmacist April 2010 www.uspharmacist.com
4/1/10 1:08 PM
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An Overview
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www.ekurie.com
laucoma is a chronic disease of the eye character- ary. Primary glaucoma refers to a glaucomatous eye
ized by progressive neuropathy of the optic nerve with no pre-existing disease, while secondary glaucoma
(ON) that can lead to irreversible blindness if results from other ocular or systemic disease, trauma,
untreated or inadequately treated. Primary open-angle or the effects of some drugs.2,4 Underlying pathology
glaucoma (POAG), the most common form of this dis- must be addressed when treating secondary glaucomas.
Primary ACG represents a medical
order, affects approximately 2.2 million
emergency because permanent blindindividuals in the United States and
U.S. Pharmacist Continuing Education
GOAL: To provide pharmacists with an
ness may quickly develop if it is not
is strongly associated with increased
overview of glaucoma and its treatment strategies.
promptly treated.4 Further discussion
intraocular pressure (IOP) and aging.1-3
OBJECTIVES: After completing this
As the proportion of elders in the U.S.
will be limited to POAG.
activity, the participant should be able to:
continues to rise, estimates target greater
1. Compare and contrast the anatomy
and physiology of the normal eye with that
ANATOMY
than 3 million cases of POAG by
of a glaucomatous eye.*
3
AND PHYSIOLOGY
2020. Because the disease is largely
2. Discuss the pathophysiology, diagnosis,
The eye is broadly divided into the
asymptomatic, many persons may be
goals of therapy, and general treatment
strategies
for
glaucoma.*
anterior and posterior segments (FIGunaware they have POAG until loss
3. Describe the pharmacologic
of vision occurs. Thus, glaucoma repURE 1). The anterior segment begins
management of primary open-angle
at the limbus and consists of the corresents an important public health
glaucoma.*
4. Discuss management strategies
nea, anterior and posterior chambers
concern. The purpose of this article
pharmacists
can
employ
to
improve
care
for
(not to be confused with anterior and
is to provide an overview of the disease
glaucoma patients.
posterior segments), pupil, iris, lens,
process and treatment strategies, allow* Also applies to pharmacy technicians.
zonules, and ciliary body. The posteing pharmacists to help improve care
rior segment lies posterior to the antefor their patients with glaucoma.
Karen K. OBrien, BS Pharm, PharmD
rior segment and consists of the vitrePharmacy Sciences Department
CLASSIFICATION
ous chamber, retina, choroid, sclera,
Creighton University School of Pharmacy &
Glaucoma is not a single disease, but
optic disc, and ON. The trabecular
Health Professions, Omaha, Nebraska
a group of disorders resulting in optic
meshwork and Schlemms canal are
Alan W. Y. Chock, PharmD
neuropathy and vision loss. These
part of the limbus, a transitional strucPharmacy Practice Department
Creighton University School of Pharmacy &
may be broadly classified as openture between the sclera and cornea
Health Professions, Omaha, Nebraska
angle or angle-closure glaucoma
(FIGURE 2). The uvea is the vascular
Catherine A. Opere, PhD
middle layer of the eye, consisting of
(ACG) based on the anatomy of the
Pharmacy Sciences Department
the iris and ciliary body in the anterior
eyes anterior chamber, and are furCreighton University School of Pharmacy &
segment and the choroid in the posther classified as primary or secondHealth Professions, Omaha, Nebraska
52
U.S. Pharmacist April 2010 www.uspharmacist.com
52 REVCE-Glaucoma 3_31rdsc.indd 52
4/1/10 1:10 PM
ANTERIOR SEGMENT
Cornea
Pupil
Iris
Lens
Ciliary body
Zonules
Sclera
POSTERIOR SEGMENT
Lateral rectus
muscle
Medial rectus
muscle
Vitreous chamber
(vitreous body)
Retina
Choroid
(mostly blood
vessels)
Retinal arteries
and veins
Aqueous Humor
Hydrodynamics
Central retinal artery
Sclera
AH functions to maintain the global
Central retinal vein
shape of the eye; supply nourishment
Optic disc
to the avascular lens, cornea, and
trabecular meshwork; and remove
Optic nerve
metabolic waste. AH also participates
Figure 1. Anatomy of the eye. Yellow arrows indicate increased intraocular pressure on the optic
in immunologic responses, contribnerve. Reprinted with permission from Creighton University SPAHP.
utes to the optical system by providterior segment.
ing a transparent refractive medium between lens and
The anterior segment is further divided into anterior cornea, and facilitates some ocular distribution of drugs.5
and posterior chambers by the lens-iris diaphragm. The AH is derived from plasma within the capillary network
anterior chamber is defined by the iris (forms the floor) of the ciliary processes (FIGURE 2) and is continually
and cornea (forms the roof) (FIGURE 2). The trabecular secreted into the posterior chamber at a rate of approximeshwork is positioned at the point where the cornea and mately 2.7 L per minute in healthy individuals.6 The
entire chamber content is replaced every
CONVENTIONAL
100 minutes to 2 hours.
PATHWAY
From the posterior chamber, AH flows
Cornea
Trabecular meshwork
through the pupil into the anterior chamCanal of Schlemm
ber to exit the eye via conventional and
Anterior
chamber
unconventional pathways. The conventional
UNCONVENTIONAL
Iris
PATHWAY
pathway accounts for the majority of outflow and refers to AH coursing through
Dilator
Sclera
the trabecular meshwork and the canal of
Sphincter
Schlemm, ultimately draining into the
systemic circulation (FIGURE 2).
In unconventional pathways, AH seeps
Posterior
through tissues rather than flowing through
chamber
the usual channels and vessels. The most
Lens
common unconventional pathway is the
uveoscleral pathway in which AH drains
Zonules
Ciliary process
from the base of the ciliary muscle, through
Ciliary
Ciliary epithelium
body
tissues in and around the uvea, and evenCiliary muscle
tually into the sclera.5
Intraocular Pressure
IOP refers to the pressure generated by
flow of AH against resistance within
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52 CE-Glaucoma 3_31rdsc.indd 53
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the retina, transmit visual information from retinal photoreceptor cells, via the ON, to the visual cortex in the brain.
Axonal fibers projecting from RGCs converge at the optic
disc and exit the eye through a meshwork of collagen fibers
known as the lamina cribosa (FIGURE 3). In addition to
RGC axons, the normal optic disc contains retinal vasculature (central artery and vein) and glial elements that
provide support and protection to the neurons. The center
of the optic disc does not contain RGC axons and is known
as the cup because it appears as a concave indentation on
ophthalmic examination (FIGURE 3).
Muller
cell
Sclera
Retinal
ganglion
cell
Glial
cell
Central
retinal
vein
Central
retinal
artery
Optic disc
Optic cup
CLINICAL FINDINGS
POAG is a chronic eye disease that is generally progressive. Typically, both eyes are
affected, although not necessarily to the same
extent. Because symptoms are minimal or
absent early in the disease process, a thorough
eye examination is essential. In establishing
Figure 3. A schematic representation of a normal (top panel) and glaucomatous (bottom a diagnosis of POAG, the clinician seeks
panel) optic disc. Elevated intraocular pressure causes posterior displacement of the gelatevidence of ON damage. Structural abnorinous lamina cribosa, resulting in degeneration of retinal ganglion cells (RGCs), RGC
axons, and surrounding structures. Progressive displacement of the lamina cribosa results malities in the optic disc or retinal nerve
bundle and/or loss of visual field confirm
in increased cup diameter. The increase in cup-to-disc ratio correlates with extent of
optic nerve damage. Reprinted with permission from Creighton University SPAHP.
damage. A dilated eye examination is preferred
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GOALS OF THERAPY
The primary purpose of therapy is to enhance the patients
quality of life by preserving vision and minimizing adverse
therapeutic effects.1,4 Goals that support therapeutic purpose include stabilizing ON/retinal nerve fiber status and
visual fields; controlling IOP; and educating and involving
the patient in disease management.1
TREATMENT STRATEGIES
All current treatment modalities aim to reduce IOP.1,4 Finding an IOP range that allows for stabilization of visual fields
and ON/retinal nerve fiber status is often a process of trial
and error. The upper limit of that range is referred to as the
target pressure. The clinician assumes pretreatment IOP
resulted in optic neuropathy and endeavors to reduce initial
IOP target pressure by at least 20%. Once therapy is initiated, IOP measurement and ON assessment guide therapeutic adjustments.1
Present options for managing glaucoma include pharmacologic therapy and surgical modalities such as laser
trabeculoplasty and filtering or cyclodestructive surgery.
Each has associated benefits and risks, and patient-specific
factors and preferences must be considered when selecting
appropriate initial therapy. Therapies may be combined
to achieve treatment goals. Topical medications are an
effective first approach in many patients, although laser
trabeculoplasty may be an acceptable option. In some
patients, filtering surgery may be preferred initially.1
RISK FACTORS
IOP is a significant risk factor in the pathogenesis of
glaucoma. There is evidence that an increase in IOP
is proportional to the prevalence of glaucoma.8 Large
variation in IOP is an additional risk factor for glaucoma. In nonglaucomatous eyes, IOP varies with
circadian rhythm by about 2 to 4 mmHg over a 24-hour
period, with peak values observed in the morning
hours.9 An increase in magnitude of variation above Surgical Management of Glaucoma
10 mmHg increases the risk of ON head (optic disc) Laser Trabeculoplasty: This procedure increases outflow
via the conventional pathway. Inflammation is the most
damage and is considered pathologic.10
In addition to elevated IOP,
common adverse effect. Pharincreasing age, family history
macologic therapy may be
Table 1. Characteristic
of glaucoma, and African or
necessary posttreatment, and
Clinical
Findings
in
POAG
Hispanic/Latino race are conbeneficial effects may dissipate
Evidence of optic nerve damage
sistently linked to an increased
over time, necessitating further
(from either or both categories)
risk of glaucoma.1-4,11 A metatreatment.4
1. Optic disc or retinal nerve fiber structural abnormality
analysis of population-based
2. Visual field abnormality
Filtering Surgery: Trabecudata identified three times the
Adult onset
Open anterior chamber angles
lotomy, which creates an alterprevalence of POAG in black
Absence of other reasons for glaucomatous changes
native pathway for AH drainas compared to white persons.
Elevated IOP (may or may not be present)
age, is often performed after
Prevalence in Hispanic/Latino
IOP:
intraocular
pressure;
POAG:
primary
open-angle
glaucoma.
medication and laser therapies
persons was similar to that in
Source: Reference 1.
have failed. Best results are
white persons except in those
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Pharmacologic
Management of Glaucoma
Medications used to manage POAG
decrease IOP by two primary mechanisms: decreasing AH production or
increasing AH outflow (through either
the conventional or unconventional
pathways). Glaucoma is a chronic diseasethere is no cure, and medical
management must be continued
throughout a persons life.
Currently, prostaglandin analogues
and beta-blockers are the most frequently
used topical medications. Sympathomimetics, topical and oral carbonic
anhydrase inhibitors, and cholinergics
are used to a lesser degree.1,4 Adverse
effects or inadequate clinical response
M.M. was treated with the recommended regimen. Her IOP normalized to 18 mmHg
may necessitate a therapeutic change,
within 3 months, following several dosage adjustments. Two years later her IOP
remains normal, and her visual fields and optic nerves are stable.
while drugs with different mechanisms
BP: blood pressure; HT: height; IOP: intraocular pressure; NLO: nasolacrimal occlusion;
of action may be used in combination
OD: right eye; OS: left eye; OU: each eye; P: pulse; PCN: penicillin; POAG: primary opento maximize IOP reduction.
angle glaucoma; RR: retinal reflex; T: temperature; WT: weight.
Many minor local adverse effects of
POAG medications are transient, and
Following instillation of topical medications, nasolacknowledge of this will encourage patients to continue
rimal occlusion (NLO) and closing the eyelid for 2
using prescribed medications. If an adverse effect does
minutes will prevent excess medication from draining
not subside, the patient should notify his or her eye
into the lacrimal ducts and greatly decrease the risk of
doctor before discontinuing use of a medication so that
systemic effects.4 Pharmacists should recommend these
another drug can be prescribed. Refer to TABLE 2 for a
summary of therapeutic and adverse effects of POAG
techniques to patients using POAG eye drops.
medications.
Instruct patients in aseptic technique to prevent conHere are some general guidelines for the pharmacist to
tamination of the container and product, and ultimately
remember when counseling patients with POAG:
the eye. The tip of the medication container must not
Systemic adverse effects are rare complications of topbe allowed to contact the patients eye or the hand of
ical glaucoma medications, but they can be serious.
whoever dispenses the drops.
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52 CE-Glaucoma 3_31rdsc.indd 56
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Brand Name
Formulation
Betaxolol
hydrochloride
Carteolol
Levobunolol
hydrochloride
Metipranolol
Timolol
Betoptic
Betoptic S
Ocupress
Betagan
Optipranolol
Betimol, Istalol,
Timoptic
Timolol-XE
0.3% solution
0.25%,0.5% solution
Dosage
0.25%,0.5%
gel-forming solution
Beta-blockers
1-2 drops BID
1 drop BID
1 drop BID
1-2 drops
Q day-BID
1 drop BID
1 drop
Q day-BID
1 drop Q day
Bimatoprost
Lumigan
0.03% solution
Prostaglandins
1 drop Q day
Latanoprost
Travoprost
Xalatan
Travatan,
Travatan Z
0.005% solution
0.004% solution
1 drop Q day
1 drop Q day
Acetazolamide
Brinzolamide
Dorzolamide
hydrochloride
Methazolamide (none in U.S.)
25-mg,
50-mg tablets
Notes
Cholinergics
Direct-acting agonists
Carbachol
Miostat
0.01% solution
Pilocarpine
Pilopine HS
4% gel
1 mL to anterior
chamber of eye
1/2-in ribbon
on lower
conjunctiva
at bedtime
Cholinesterase inhibitor
Echothiophate
iodide
Phospholine
Iodide
1 drop BID
Sympathomimetics
1 drop BID
1-2 drops BID
AH: aqueous humor; CAIs: carbonic anhydrase inhibitors; COPD: chronic obstructive pulmonary disease; ER: extended release; Max: maximum.
Source: References 27, 28.
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Therapy
Doses per day
Cost
Adverse effects
Complexity of regimen
Provider
Rapport with patient
Patient perception of provider skill
Life Circumstances
Lack of support system
Traveling/vacation
Transportation
Complicated lifestyle
52 CE-Glaucoma 3_31rdsc.indd 58
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52 CE-Glaucoma 3_31rdsc.indd 59
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CONCLUSION
Glaucoma, strongly associated with aging and vision loss,
is a serious public health concern in the U.S. because the
proportion of elderly persons in the population is rapidly
growing. Elevated IOP, along with other as yet unidentified
factors, contributes to optic neuropathy and vision loss. All
current treatment modalities are aimed at lowering IOP,
and adherence to medical therapy is important in preserving vision. Pharmacists may positively impact outcomes by
providing education about glaucoma, describing proper use
of prescribed medications, identifying barriers to treatment
adherence, and developing strategies to help patients overcome obstacles to successful management of glaucoma.
The authors gratefully acknowledge the editorial assistance of
Janet Shea, BSN, MPA.
References available online at www.uspharmacist.com.
Disclosure Statements:
Drs. OBrien, Chock, and Opere have no actual or potential conflicts of
interest in relation to this activity.
U.S. Pharmacist does not view the existence of relationships as an implication of bias or that the value of the material is decreased. The content of the
activity was planned to be balanced, objective, and scientifically rigorous.
Occasionally, authors express opinions that represent their own viewpoint.
Conclusions drawn by participants should be derived from objective analysis
of scientific data.
Disclaimer:
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The
information presented in this activity is not meant to serve as a guideline for
patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by
clinicians without evaluation of their patients conditions and possible contraindications or dangers in use, review of any applicable manufacturers product
information, and comparison with recommendations of other authorities.
EXAMINATION
Select one correct answer for each question and record your responses
on the examination answer sheet. Mail it to U.S. Pharmacist, address
shown on the answer sheet (photocopies are acceptable). Please allow
four weeks for processing. Alternatively, this exam can be taken online
at www.uspharmacist.com. Please contact CE Customer Service at
(800) 825-4696 or cecustomerservice@jobson.com with any questions.
2 CE Credits
An Overview of Glaucoma
Management for Pharmacists
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52 REVCE-Glaucoma 3_31rdsc.indd 60
4/1/10 1:10 PM
AN OVERVIEW OF GLAUCOMA
An Overview of Glaucoma
Management for Pharmacists
Directions: Select one answer for each question in the exam and completely darken
the appropriate circle. A minimum score of 70% is required to earn credit. An identifier
is required to process your exam. This is used for internal processing purposes only.
Mail to: U.S. PharmacistCE, PO Box 487, Canal Street Station, New York, NY 10013
Check one:
Payment:
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Check is enclosed (payable to Jobson Medical Information LLC)
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Signature:
from date of receipt
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(Example: FL12345678)
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The following is your:
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Name
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Profession:
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By submitting this answer sheet, I certify that I have read the lesson in its entirety and
completed the self-assessment exam personally based on the material presented.
I have not obtained the answers to this exam by any fraudulent or improper means.
Signature
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Accreditation Council for Pharmacy Education as a provider
of continuing pharmacy education.
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52 REVCE-Glaucoma 3_31rdsc.indd 61
Lesson 106698
0430-0000-10-007-H01-P
0430-0000-10-007-H01-T
4/1/10 1:11 PM
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PA Coudersport;
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Pharmacy Technicians
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Springs (PRN);
Together we are
Essential to care
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Pharmacy Law
Steroid Marketing
Convictions
The illegal distribution
of anabolic steroids and
human growth hormone
can cost pharmacists
their licenses and more.
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Anabolic Steroids
According to the DEA, anabolic steroids are a class of drugs with a basic
steroid ring structure that produce
anabolic and androgenic effects. The
chemicals are synthetically produced
variants of the naturally occurring
male hormone testosterone. Both
males and females produce testosterone in their bodies: males in the testes and females in the ovaries and
other tissues. The full name for this
class of drugs is androgenic (promoting masculine characteristics) anabolic (tissue-building) steroids (the
class of drugs).20 Athletes, bodybuilders, and others abuse anabolic
REFERENCES
1. Kirby B. Jury finds 5 guilty in Mobile steroids conspiracy
case. Alabama Live LLC. February 8, 2010.
http://blog.al.com/live/2010/02/jury_convicts_owners_of_
applie.html. Accessed February 17, 2010.
2. Vinton N, OKeeffe M. Arizona naturopath Jesse Haggard
faces music in steroid prosecution. NY Daily News. October 7,
2009. www.nydailynews.com/sports/2009/10/07/2009-10-07_
steroids.html. Accessed February 24, 2010.
3. Associated Press. Mobile business owner pleads guilty to
steroid distribution. October 19, 2009.
http://wkrg.com/460434. Accessed February 17, 2010.
4. Baker M. Political grandstanding in Applied Pharmacy Services indictment for steroid distribution. MesoRx. January 23,
2010. www.mesomorphosis.com/blog/2009/01/23/indictmentagainst-applied-pharmacy-services-steroid-distribution-network/.
Accessed February 17, 2010.
5. Kirby B. Mobile steroids trial nearing end; Applied Pharmacy
charged with supplying star athletes. Alabama Live LLC.
February 2, 2010. http://blog.al.com/live/2010/02/lawyers_
debate_steroids_sales.html. Accessed February 17, 2010.
6. See Note 4, supra.
7. OKeeffe M. Pharmacy owners indicted for role in performance-enhancing drug ring. NY Daily News. January 24, 2009.
www.nydailynews.com/sports/2009/01/23/2009-01-23_
pharmacy_owners_indicted_for_role_in_per.html.
Analysis
Steroids, growth hormones, and
related drugs all have legitimate therapeutic uses, and compounding of
specialty products for unique situations is at the core of good pharmacy practice. But, as demonstrated
by the above cases, there are limits
that cannot be exceeded, lest the
power of law come knocking on
your door. Compounding medications requires a prescription that
comes from a licensed prescriber acting in the normal course of practice
for an individual with whom the
prescriber has a legitimate patient
relationship, and is issued for a legal
medical purpose. Staying within
these guidelines will ensure that
pharmacists are engaged in useful,
valid practices.
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64 Law 3_30bosc.indd 66
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BRIEF SUMMARY
pharmacokinetics of pramipexole.
Amantadine
Population pharmacokinetic analysis suggests that amantadine may
slightly decrease the oral clearance of pramipexole.
Cimetidine
Cimetidine, a known inhibitor of renal tubular secretion of organic
bases via the cationic transport system, caused a 50% increase in
pramipexole AUC and a 40% increase in half-life (N=12).
Probenecid
Probenecid, a known inhibitor of renal tubular secretion of organic
acids via the anionic transporter, did not noticeably inuence
pramipexole pharmacokinetics (N=12).
Other Drugs Eliminated Via Renal Secretion
Population pharmacokinetic analysis suggests that coadministration
of drugs that are secreted by the cationic transport system (e.g.,
cimetidine, ranitidine, diltiazem, triamterene, verapamil, quinidine,
and quinine) decreases the oral clearance of pramipexole by about
20%, while those secreted by the anionic transport system (e.g.,
cephalosporins, penicillins, indomethacin, hydrochlorothiazide, and
chlorpropamide) are likely to have little effect on the oral clearance
of pramipexole.
CYP Iinteractions
Inhibitors of cytochrome P450 enzymes would not be expected to
affect pramipexole elimination because pramipexole is not appreciably
metabolized by these enzymes in vivo or in vitro. Pramipexole does
not inhibit CYP enzymes CYP1A2, CYP2C9, CYP2C19, CYP2E1, and
CYP3A4. Inhibition of CYP2D6 was observed with an apparent Ki of
30 M, indicating that pramipexole will not inhibit CYP enzymes at
plasma concentrations observed following the clinical dose of 4.5 mg/
day (1.5 mg TID).
Dopamine Antagonists
Since pramipexole is a dopamine agonist, it is possible that
dopamine antagonists, such as the neuroleptics (phenothiazines,
butyrophenones, thioxanthenes) or metoclopramide, may diminish
the effectiveness of pramipexole dihydrochloride tablets.
Drug/Laboratory Test Interactions
There are no known interactions between pramipexole dihydrochloride
tablets and laboratory tests.
Carcinogenesis, Mutagenesis, Impairment of Fertility
Two year carcinogenicity studies with pramipexole have been
conducted in mice and rats. Pramipexole was administered in the diet
to Chbb:NMRI mice at doses of 0.3, 2, and 10 mg/kg/day (0.3, 2.2,
and 11 times the maximum recommended human dose [MRHD of
1.5 mg TID on a mg/m2 basis). Pramipexole was administered in the
diet to Wistar rats at 0.3, 2, and 8 mg/kg/day (plasma AUCs were 0.3,
2.5, and 12.5 times the AUC in humans at the MRHD). No signicant
increases in tumors occurred in either species.
Pramipexole was not mutagenic or clastogenic in a battery of assays,
including the in vitro Ames assay, V79 gene mutation assay for
HGPRT mutants, chromosomal aberration assay in Chinese hamster
ovary cells, and in vivo mouse micronucleus assay.
In rat fertility studies, pramipexole at a dose of 2.5 mg/kg/day (5
times the MRHD on a mg/m2 basis), prolonged estrus cycles and
inhibited implantation. These effects were associated with reductions
in serum levels of prolactin, a hormone necessary for implantation
and maintenance of early pregnancy in rats.
Pregnancy
Teratogenic Effects
Pregnancy Category C
When pramipexole was given to female rats throughout pregnancy,
implantation was inhibited at a dose of 2.5 mg/kg/day (5 times the
maximum recommended human dose [MRHD] on a mg/m2 basis).
Administration of 1.5 mg/kg/day of pramipexole to pregnant rats
during the period of organogenesis (gestation days 7 through 16)
resulted in a high incidence of total resorption of embryos. The plasma
AUC in rats at this dose was 4 times the AUC in humans at the MRHD.
These ndings are thought to be due to the prolactin lowering effect
of pramipexole, since prolactin is necessary for implantation and
maintenance of early pregnancy in rats (but not rabbits or humans).
Because of pregnancy disruption and early embryonic loss in these
studies, the teratogenic potential of pramipexole could not be
adequately evaluated. There was no evidence of adverse effects on
embryo fetal development following administration of up to 10 mg/
kg/day to pregnant rabbits during organogenesis (plasma AUC was 71
times that in humans at the MRHD). Postnatal growth was inhibited
in the offspring of rats treated with 0.5 mg/kg/day (approximately
equivalent to the MRHD on a mg/m2 basis) or greater during the latter
part of pregnancy and throughout lactation.
There are no studies of pramipexole in human pregnancy. Because
animal reproduction studies are not always predictive of human
response, pramipexole should be used during pregnancy only if the
potential benet outweighs the potential risk to the fetus.
Nursing Mothers
A single-dose, radio-labeled study showed that drug-related materials
were excreted into the breast milk of lactating rats. Concentrations of
radioactivity in milk were three to six times higher than concentrations
in plasma at equivalent time points.
Other studies have shown that pramipexole treatment resulted in an
inhibition of prolactin secretion in humans and rats.
It is not known whether this drug is excreted in human milk. Because
many drugs are excreted in human milk and because of the potential
for serious adverse reactions in nursing infants from pramipexole, a
decision should be made as to whether to discontinue nursing or to
discontinue the drug, taking into account the importance of the drug
to the mother.
Pediatric Use
The safety and efcacy of pramipexole dihydrochloride tablets in
pediatric patients has not been established.
Geriatric Use
Pramipexole total oral clearance was approximately 30% lower
in subjects older than 65 years compared with younger subjects,
because of a decline in pramipexole renal clearance due to an agerelated reduction in renal function. This resulted in an increase in
elimination half-life from approximately 8.5 hours to 12 hours. In
clinical studies with Parkinsons disease patients, 38.7% of patients
were older than 65 years. There were no apparent differences in
efcacy or safety between older and younger patients, except that the
relative risk of hallucination associated with the use of pramipexole
dihydrochloride tablets was increased in the elderly.
ADVERSE REACTIONS
Parkinsons Disease
During the premarketing development of pramipexole, patients with
either early or advanced Parkinsons disease were enrolled in clinical
trials. Apart from the severity and duration of their disease, the two
populations differed in their use of concomitant levodopa therapy.
Patients with early disease did not receive concomitant levodopa
14
12
General Edema
Malaise
Reaction unevaluable
Fever
Nausea
28
18
Constipation
14
4
2
2
0
Disgestive System
Anorexia
Dysphagia
Metabolic &
Nutritional System
Peripheral edema
Decreased weight
17
Asthenia
10
General edema
Chest pain
53
48
10
Dizziness
25
Somnolence
22
Malaise
Cardiovascular
System
Postural hypotension
Insomnia
17
12
Digestive System
Hallucinations
Confusion
Amnesia
Hypesthesia
Dystonia
Akathisia
Thinking
Abnormalities
Decreased libido
Myoclonus
Nervous System
24
Special Senses
Vision abnormalities
Urogenital System
Impotence
2
1
*Patients may have reported multiple adverse experiences
during the study or at discontinuation; thus, patients may
be included in more than one category.
Other events reported by 1% or more of patients with early Parkinsons
disease and treated with pramipexole dihydrochloride tablets but
Constipation
Dry mouth
Metabolic &
Nutritional System
Peripheral edema
Increased creatine
PK
Musculoskeletal
System
Arthritis
15
Twitching
Bursitis
Myasthenia
47
31
28
26
27
26
22
25
Nervous System
Dyskinesia
Extrapyramidal
syndrome
Insomnia
Dizziness
(contd)
11
10
Confusion
10
Somnolence
Dystonia
Gait abnormalities
Hypertonia
Amnesia
Akathisia
Thinking
abnormalities
Paranoid reaction
Delusions
Sleep disorders
Dyspnea
Rhinitis
Pneumonia
Respiratory System
Eye disorders
amaurosis
fugax,
blepharitis,
blepharospasm,
cataract,
dacryostenosis acquired, dry eye, eye hemorrhage, eye irritation,
eye pain, eyelid edema, eyelid ptosis, glaucoma, keratitis, macular
degeneration, myopia, photophobia, retinal detachment, retinal
vascular disorder, scotoma, vision blurred, visual acuity reduced,
vitreous oaters
Gastrointestinal disorders
abdominal discomfort, abdominal distension, aphthous stomatitis,
ascites, cheilitis, colitis, colitis ulcerative, duodenal ulcer, duodenal
ulcer hemorrhage, enteritis, eructation, fecal incontinence, gastric
ulcer, gastric ulcer hemorrhage, gastritis, gastrointestinal hemorrhage,
gastroesophageal reux disease, gingivitis, haematemesis,
haematochezia, hemorrhoids, hiatus hernia, hyperchlorhydria, ileus,
inguinal hernia, intestinal obstruction, irritable bowel syndrome,
esophageal spasm, esophageal stenosis, esophagitis, pancreatitis,
periodontitis, rectal hemorrhage, reux esophagitis, tongue edema,
tongue ulceration, toothache, umbilical hernia
General disorders
chest discomfort, chills, death, drug withdrawal syndrome, face
edema, feeling cold, feeling hot, feeling jittery, gait disturbance,
impaired healing, inuenza-like illness, irritability, localized edema,
edema, pitting edema, thirst
Hepatobiliary disorders
biliary colic, cholecystitis, cholecystitis chronic, cholelithiasis
Immune system disorders
drug hypersensitivity
Infections and infestations
abscess, acute tonsillitis, appendicitis, bronchiolitis, bronchitis,
bronchopneumonia, cellulitis, cystitis, dental caries, diverticulitis,
ear infection, eye infection, folliculitis, fungal infection, furuncle,
gangrene, gastroenteritis, gingival infection, herpes simplex,
herpes zoster, hordeolum, intervertebral discitis, laryngitis, lobar
pneumonia, nail infection, onychomycosis, oral candidiasis, orchitis,
osteomyelitis, otitis externa, otitis media, paronychia, pyelonephritis,
pyoderma, sepsis, skin infection, tonsillitis, tooth abscess, tooth
infection, upper respiratory tract infection, urethritis, vaginal
candidiasis, vaginal infection, viral infection, wound infection
Injury, poisoning and procedural complications
accidental falls, drug toxicity epicondylitis, road trafc accident,
sunburn, tendon rupture
Metabolism and nutrition disorders
cachexia, decreased appetite, dehydration, diabetes mellitus, uid
retention, gout, hypercholesterolemia, hyperglycemia, hyperlipidemia,
hyperuricemia,
hypocalcemia,
hypoglycemia,
hypokalemia,
hyponatremia, hypovitaminosis, increased appetite, metabolic alkalosis
Musculoskeletal and connective tissue disorders
bone pain, fasciitis, ank pain, intervertebral disc disorder,
intervertebral disc protrusion, joint effusion, joint stiffness,
joint swelling, monarthritis, muscle rigidity, muscle spasms,
musculoskeletal stiffness, myopathy, myositis, nuchal rigidity,
osteoarthritis, osteonecrosis, osteoporosis, polymyalgia, rheumatoid
arthritis, shoulder pain, spinal osteoarthritis, tendonitis, tenosynovitis
Neoplasms benign, malignant and unspecied
abdominal neoplasm, adenocarcinoma, adenoma benign, basal cell
carcinoma, bladder cancer, breast cancer, breast neoplasm, chronic
lymphocytic leukemia, colon cancer, colorectal cancer, endometrial
cancer, gallbladder cancer, gastric cancer, gastrointestinal neoplasm,
hemangioma, hepatic neoplasm, hepatic neoplasm malignant, lip
and/or oral cavity cancer, lung neoplasm malignant, lung cancer
metastatic, lymphoma, malignant melanoma, melanocytic naevus,
metastases to lung, multiple myeloma, oral neoplasm benign,
neoplasm, neoplasm malignant, neoplasm prostate, neoplasm skin,
neuroma, ovarian cancer, prostate cancer, prostatic adenoma, pseudo
lymphoma, renal neoplasm, skin cancer, skin papilloma, squamous
cell carcinoma, thyroid neoplasm, uterine leiomyome
Nervous system disorders
ageusia, akinesia, anticholinergic syndrome, aphasia, balance
disorder, brain edema, carotid artery occlusion, carpal tunnel
syndrome, cerebral artery embolism, cerebral hemorrhage, cerebral
infarction, cerebral ischemia, chorea, cognitive disorder, coma,
convulsion, coordination abnormal, dementia, depressed level
of consciousness, disturbance in attention, dizziness postural,
dysarthria, dysgraphia, facial palsy, grand mal convulsion,
hemiplegia,
hyperaesthesia,
hyperkinesia,
hyperreexia,
hyporeexia, hypotonia, lethargy, loss of consciousness, memory
impairment, migraine, muscle contractions involuntary, narcolepsy,
neuralgia, neuropathy, nystagmus, parosmia, psychomotor
hyperactivity, sciatica, sedation, sensory disturbance, sleep phase
rhythm disturbance, sleep talking, stupor, syncope vasovagal,
tension headache
Psychiatric disorders
affect lability, aggression, agitation, bradyphrenia, bruxism, suicide,
delirium, delusional disorder persecutory type, disorientation,
dissociation, emotional distress, euphoric mood, hallucination
auditory, hallucination visual, initial insomnia, libido increased, mania,
middle insomnia, mood altered, nightmare, obsessive thoughts,
obsessive-compulsive disorder, panic reaction, parasomnia,
personality disorder, psychotic disorder, restlessness, sleep walking,
suicidal ideation
Renal and urinary disorders
chromaturia, dysuria, glycosuria, hematuria, urgency, nephrolithiasis,
neurogenic bladder, nocturia, oliguria, pollaciuria, proteinuria, renal
artery stenosis, renal colic, renal cyst, renal failure, renal impairment,
urinary retention
Reproductive system and breast disorders
amenorrhea, breast pain, dysmenorrhea, epididymitis, gynaecomastia,
menopausal symptoms, menorrhagia, metrorrhagia, ovarian cyst,
priapism, prostatitis, sexual dysfunction, uterine hemorrhage, vaginal
discharge, vaginal hemorrhage
Respiratory, thoracic and mediastinal disorders
apnea, aspiration, asthma, choking, chronic obstructive pulmonary
disease, dry throat, dysphonia, dyspnea exertional, epistaxis,
haemoptysis, hiccups, hyperventilation, increased bronchial
secretion, laryngospasm, nasal dryness, nasal polyps, obstructive
airways disorder, pharyngolaryngeal pain, pleurisy, pneumonia
aspiration, pneumothorax, postnasal drip, productive cough,
pulmonary embolism, pulmonary edema, respiratory alkalosis,
respiratory distress, respiratory failure, respiratory tract congestion,
rhinitis allergic, rhinorrhea, sinus congestion, sleep apnea syndrome,
sneezing, snoring, tachypnea, wheezing
Skin and subcutaneous tissue disorders
acne, alopecia, cold sweat, dermal cyst, dermatitis, dermatitis
bullous, dermatitis contact, dry skin, ecchymosis, eczema, erythema,
hyperkeratosis, livedo reticularis, night sweats, periorbital edema,
petechiae, photosensitivity allergic reaction, psoriasis, purpura, rash
Starting Dose
(mg)
Maximum Dose
(mg)
0.125 tid
1.5 tid
0.125 bid
1.5 bid
0.125 qd
1.5 qd
ANIMAL TOXICOLOGY
Retinal Pathology in Albino Rats
Pathologic changes (degeneration and loss of photoreceptor cells)
were observed in the retina of albino rats in the 2 year carcinogenicity
study with pramipexole. These ndings were rst observed during
week 76 and were dose dependent in animals receiving 2 or 8 mg/kg/
day (plasma AUCs equal to 2.5 and 12.5 times the AUC in humans that
received 1.5 mg tid). In a similar study of pigmented rats with 2 years
exposure to pramipexole at 2 or 8 mg/kg/day, retinal degeneration
was not diagnosed. Animals given drug had thinning in the outer
nuclear layer of the retina that was only slightly greater than that seen
in control rats utilizing morphometry.
Investigative studies demonstrated that pramipexole reduced the
rate of disk shedding from the photoreceptor rod cells of the retina
in albino rats, which was associated with enhanced sensitivity to the
damaging effects of light. In a comparative study, degeneration and
loss of photoreceptor cells occurred in albino rats after 13 weeks of
treatment with 25 mg/kg/day of pramipexole (54 times the highest
clinical dose on a mg/m2 basis) and constant light (100 lux) but not in
pigmented rats exposed to the same dose and higher light intensities
(500 lux). Thus, the retina of albino rats is considered to be uniquely
sensitive to the damaging effects of pramipexole and light. Similar
changes in the retina did not occur in a 2 year carcinogenicity study
in albino mice treated with 0.3, 2, or 10 mg/kg/day (0.3, 2.2 and 11
times the highest clinical dose on a mg/m2 basis). Evaluation of the
retinas of monkeys given 0.1, 0.5, or 2 mg/kg/day of pramipexole
(0.4, 2.2, and 8.6 times the highest clinical dose on a mg/m2 basis) for
12 months and minipigs given 0.3, 1, or 5 mg/kg/day of pramipexole
for 13 weeks also detected no changes.
The potential signicance of this effect in humans has not been
established, but cannot be disregarded because disruption of a
mechanism that is universally present in vertebrates (i.e., disk
shedding) may be involved.
Fibro-osseous Proliferative Lesions in Mice
An increased incidence of bro-osseous proliferative lesions occurred
in the femurs of female mice treated for 2 years with 0.3, 2, or 10 mg/
kg/day (0.3, 2.2, and 11 times the highest clinical dose on a mg/m2
basis). Lesions occurred at a lower rate in control animals. Similar
lesions were not observed in male mice or rats and monkeys of either
sex that were treated chronically with pramipexole. The signicance
of this lesion to humans is not known.
Manufactured By:
BARR LABORATORIES, INC.
Pomona, NY 10970
Manufactured For:
TEVA PHARMACEUTICALS USA
Sellersville, PA 18960
Iss. 8/2009
PATIENT INFORMATION ABOUT PRAMIPEXOLE DIHYDROCHLORIDE
TABLETS
Read the Patient Information that comes with pramipexole before you
start taking it and each time you get a rell. There may be some new
information. This leaet does not take the place of talking with your
doctor about your medical condition or your treatment.
What is the most important information I should know about
pramipexole?
Pramipexole may cause you to fall asleep while you are doing daily
activities such as driving, talking with other people, watching TV,
or eating.
Tevas
Pramipexole Dihydrochloride
Tablets
AB Rated and Bioequivalent to
Mirapex* Tablets
SIZE
NDC#
0.125 mg
63
00555-0617-62
0.25 mg
90
00555-0612-14
0.5 mg
90
00555-0613-14
1 mg
90
00555-0614-14
1.5 mg
90
00555-0615-14