CASE 1: TREATMENT OF CHRONIC DRY EYE
Q: BC, a 65-year-old woman, is looking for advice about treating her chronically dry, irritated eyes. She reports frequently experiencing a gritty feeling, like there is something in her eyes, and wants to know if the pharmacist notices a mild redness of her sclera. At BC’s last medical appointment, when she mentioned these symptoms, her physician encouraged her to use a lubricant eye drop, but she was not sure what that meant and never followed up. BC’s medical history includes gastroesophageal reflux disease, hypertension, hypothyroidism, and Parkinson disease, and she takes many medications. She says she is allergic to penicillin and sulfonamide. What recommendations do you have?

A: Dry eye disease (DED) is a common health complaint, estimated to account for up to 25% of ophthalmic clinic visits.1 Symptoms of DED often include ocular discomfort, visual changes or disturbance, and disordered tear production, which can occur chronically or episodically. This condition represents a disorder attributed to multifactorial causes: autoimmune disease, environmental factors, hormonal fluctuations, increasing age, inflammation, and a variety of medications, including antidepressants, antihistamines, diuretics, and hormone contraceptives and replacement therapies.1,2 This condition is particularly common in postmenopausal women, as illustrated by BC’s presentation.

In addition to patient education and medication, pharmacists should identify drugs that may exacerbate symptoms. In BC’s case, conducting a review of her medication profile is warranted, as is recommending an OTC artificial tear solution, which can be instilled into the eye 1 to 2 times daily depending on the selected product, with frequency increased up to 3 to 4 times a day as needed.Ocular lubricants represent the first-line approach for alleviating irritation of the ocular surface. For persistent symptoms, encourage BC to follow up with her primary care provider or an eye care specialist for further management.

CASE 2: ALLERGIC CONJUNCTIVITIS
Q: ST, a 28-year-old man, asks about an OTC treatment option to relieve seasonal allergy symptoms. He reports experiencing allergic rhinitis and irritated eyes twice a year during the spring and fall, which he attributes to seasonal allergies. ST denies cough, fever, or other systemic symptoms. In addition to the nasal congestion and rhinorrhea, he has ocular itching and redness that don’t seem to be relieved with use of his intranasal corticosteroid or daily montelukast tablets. ST reports excessive tearing, which is causing occasional blurred vision, but he does not wear contact lenses or glasses. He takes no other medications and reports no allergies to medications. What recommendations do you have?  

A: Allergic conjunctivitis, a condition characterized by ocular pruritus and red, watery eyes, is a common occurrence in individuals suffering from seasonal allergies, as in ST’s case. Numerous environmental allergens, including dander and pollen, can cause patients to suffer from eye irritation.2 In providing education on the management of allergic conjunctivitis symptoms, counsel patients on strategies related to allergen or trigger avoidance, therapies that may mitigate ocular symptoms and the severity of the reaction, and how to protect the eye surface from damage.2,3 For ST, underscore the importance of nonpharmacologic approaches, such as applying cool compresses to provide relief from pruritis, changing air filters in the home, and staying indoors on days when pollen counts are high—although these interventions alone are not likely to resolve his symptoms. For nonprescription options, artificial tear drops could be recommended as an initial approach, with ketotifen eye drops the next intervention for persistent symptoms. Counsel ST on the judicious use of ophthalmic decongestants, too. However, while these agents may provide quick relief of ocular redness, they do not address the underlying cause of symptoms and rebound congestion can result from indiscriminate use.2 

CASE 3: PREVENTING DIABETIC RETINOPATHY
Q: TW, a 48-year-old woman, is seeking information on how she can prevent diabetic eye disease. Her medical history includes hypertension, dyslipidemia, and type 2 diabetes for the past several years. TW says she is compliant with her recommended diet, is physically active each day, and takes several medications, including atorvastatin, lisinopril, and metformin/sitagliptin each day. She recently participated in a diabetes education course at the recommendation of her primary care provider, where she learned about the importance of receiving a comprehensive eye examination each year. After receiving this education, TW was not sure about how imperative it was to make an appointment for an eye exam, because she has never experienced vision problems. She wants information and a recommendation about how to protect her eyes and guidance about her eye exam visit. What rAecommendations do you have?

A: Diabetic retinopathy, a specific microvascular complication that can affect individuals with type 1 or type 2 diabetes, is attributed to a number of factors, including degree of glycemic control, duration of diabetes, and the presence of other ocular conditions or microvascular complications, including nephropathy. In TW’s case, her comorbid dyslipidemia and hypertension may also increase her risk of developing microvascular complications, such as retinopathy.4,5 She should be reminded that the best things to reduce the risk of eye disease include controlling her blood glucose, blood pressure, and lipid values, according to a recent position statement from the American Diabetes Association.5 In counseling TW, underscore the importance of adherence to a therapeutic lifestyle, which may include dietary education and modification, exercise recommendations, weight loss if indicated, and the importance of compliance with prescription medications. She should be encouraged to follow up with a comprehensive eye exam, as was suggested in her education class. Any vision changes, including blurry or double vision, eye pain, or floaters, should be evaluated by an ophthalmologist immediately.4,5 

CASE 4: HERPES ZOSTER
Q: LL is a 66-year-old woman who is looking for papain tablets. She said that she read that the tablets can help with herpes zoster (shingles). Some of LL’s friends had shingles, and a few of them tried the tablets and found them beneficial. She has never had shingles but wants to take the tablets preventively. LL’s immunization card shows that she has the influenza vaccine yearly and that she had the pneumococcal conjugate vaccine 13 at age 65, the pneumococcal polysaccharide vaccine 23 at age 66, and the tetanus, diphtheria, and pertussis vaccine at age 63. All of her childhood vaccinations are up-to-date. LL’s medical history includes hypertension, which she manages through diet. Upon questioning, she says that she has not received the herpes zoster vaccine. LL was confused about which to get, so she avoided the tablets and the vaccine. What recommendations do you have?

A: LL should be told that the results of one study show that papain may be beneficial for herpes zoster symptoms, but that the trial was a small study and that more studies need to be conducted before recommending papain for symptom management. There are no study results that show papain would be beneficial for the prevention of herpes zoster. The Advisory Committee on Immunization Practices (ACIP) recommends Shingrix (recombinant zoster vaccine) over Zostavax (zoster vaccine live) for the prevention of herpes zoster and related complications. In clinical studies, the results of the recombinant zoster vaccine showed that 2 doses administered 2 months apart had an efficacy of 97.2% in reducing the risk of herpes zoster compared with placebo. The zoster vaccine live had an initial efficacy of 51%, which increased slightly in phase 4 studies. As a result, ACIP has replaced zoster vaccine live with recombinant zoster vaccine as its first-line recommendation for the prevention of shingles. If patients have previously received a dose of zoster vaccine live, they should be revaccinated with the recombinant zoster vaccine. Another difference between the 2 vaccines is that zoster vaccine live is a 1-dose (0.5-mL) vaccine, while 2 doses (0.5 mL) must be given for the recombinant zoster vaccine, the second dose of which must be given within 2 to 6 months of the first dose. Also, zoster vaccine live is a live attenuated vaccine approved for patients 60 years and older, while recombinant zoster vaccine is approved for patients 50 years and older.6

In June 2018, the CDC said, “Due to high levels of demand for GSK’s [GlaxoSmithKline’s] Shingrix vaccine, GSK has implemented order limits and providers have experienced shipping delays. It is anticipated these order limits and shipping delays will continue throughout 2018. In response, GSK has increased the US supply available for 2018 and plans to release doses to all customer types on a consistent and predictable schedule for the rest of 2018. Overall, the supply of Shingrix during 2018 is sufficient to support the vaccination of more patients during 2018 than were vaccinated against shingles during 2017.”7

Based on the delays, it may be difficult for LL to get the vaccination. Advise her that checking with multiple offices or pharmacies is important, because the vaccine supply is being shipped to many locations. In addition, if LL receives the first dose but has difficulty obtaining the second dose, she can always increase the interval. Although the delay will not affect the way the vaccine works or its efficacy, it will delay being fully protected until both doses are obtained.
 
Mary Barna Bridgeman, PharmD, BCPS, BCGP, is a clinical associate professor at the Ernest Mario School of Pharmacy at Rutgers University in Piscataway, New Jersey, and an internal medicine clinical pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.

Rupal Patel Mansukhani, PharmD, is a clinical associate professor at the Ernest Mario School of Pharmacy and a transitions-of-care clinical pharmacist at Morristown Medical Center in New Jersey.


References
  1. Gayton JL. Etiology, prevalence, and treatment of dry eye disease. Clin Ophthalmol. 2009;3:405-412.
  2. Fiscella RG, Jensen MK. Ophthalmic disorders. In: Krinsky DL Ferreri SP, Hemstreet, B, et al, eds. Handbook of Nonprescription Drugs. 19th ed. Washington, DC: American Pharmacists Association;2018.
  3. Bielory L. Occular allergy review. Immunol Allergy Clin North Am. 2008;28(1):1-23. doi: 10.1016/j.iac.2007.12.011.
  4. American Diabetes Association. Microvascular complications and foot care: standards of medical care in diabetes-2018. Diabetes Care. 2018;41(suppl 1):S105-S118. doi: 10.2337/dc18-S010.
  5. Solomon SD, Chew E, Duh EJ, et al. Diabetic retinopathy: a position statement by the American Diabetes Association [erratum in Diabetes Care. 2017;40(9):1285. doi: 10.2337/dc17-er09. Diabetes Care. 2017;40(6):809. doi: 10.2337/dc17-er06e]. Diabetes Care. 2017;40(3):412-418. doi: 10.2337/dc16-2641.
  6. Shingrix recommendations. CDC website. cdc.gov/vaccines/vpd/shingles/hcp/shingrix/recommendations.html. Updated August 22, 2018. Accessed September 7, 2018.
  7. Current vaccine shortages & delays. CDC website. cdc.gov/vaccines/hcp/clinical-resources/shortages.html. Updated July 5, 2018. Accessed September 5, 2018.