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Specialist prescribing restrictions have been removed from some topical eye treatments from 1st October 2007. These include medications from the following groups.

  • Antiviral
  • Antibacterial
  • Steroidal anti-inflammatory
  • Non-steroidal anti-inflammatory
  • Intraocular pressure reducing

Key points

  • Although general practitioners can now initiate some topical eye treatments, it does not mean they should.
  • Significant corneal disease, intraocular inflammation and glaucoma still require specialist diagnosis and management.
  • Primary care will still be involved in the ongoing support and education of people with these conditions and the continuation of the medications used to treat them.

High risk situations requiring specialist skills

Some of these medications are used when there is high risk of visual loss and their misuse can increase this risk. Initiation and monitoring require high levels of knowledge, skills and experience of a specialist nature as well as the availability and ability to use specialist equipment. For example:

  • Slit-lamp examination is needed for accurate diagnosis and monitoring of intraocular inflammation, such as iritis and keratitis, and ulceration of the cornea.
  • Accurate diagnosis and monitoring for adequacy of treatment of glaucoma requires accurate detailed assessment of intraocular pressure, the optic disk and visual fields.
  • Accurate distinction between infective and non-infective inflammatory conditions is essential because medications, such as steroid drops, used for some conditions, will make others much worse.
  • Use of steroid drops for more than ten days requires, monitoring for steroid-induced glaucoma.

Primary care role still important

Although primary care is often not equipped to initiate and monitor treatment for these conditions, it still plays a valuable role. People will still look to primary care for support, education and continuation of treatment. Clinicians, particularly prescribers, need to understand the actions of these medications and how to avoid and identify possible adverse effects. For example:

  • Some topical preparations e.g. beta-blockers, are sufficiently absorbed to cause systemic effects.
  • Unless medically indicated, soft contact lenses should not be used for the duration of treatment with eye drops and ointments.
  • However, it is safe to replace contact lenses 15 minutes after use of some drops.
  • Application of gentle pressure to the tear duct after instilling drops increases exposure of the anterior eye tissues to the treatment and reduces systemic absorption. This is especially advisable in children.

Resource for updating primary care clinicians about eye medications

bpacnz does not expect to see changes in the way general practitioners use topical eye medications as a result in this change in availability. However it does offer an opportunity to update knowledge in this area.

To help with this bpacnz is producing a more detailed guide to update GPs about topical eye treatments. This will be available in the next issue of BPJ.

Be aware of OTC sumatriptan use by people with migraine

Sumatriptan 50 mg is now available for sale as a pharmacist only medicine.

Pharmacists have been given strict criteria concerning over the counter sales.

The purchaser must have an established pattern of migraine symptoms and the product can only be sold in an original pack of two tablets along with an information leaflet.

In those with a definitive diagnosis of migraine, sumatriptan is often an effective treatment. It works best when taken early in the painful phase of a migraine headache and unlike simple analgesics, is less effective when taken during the aura.

There is a significant risk of relapse with sumatriptan (within 48 hours) in up to 50% of patients. The dose can be repeated but is usually less effective the second time. Use of sumatriptan or analgesics on more than two days per week is associated with significant risk of medication overuse headache. Establishing a clear history regarding previous use is essential.

In general, it is recommended that all patients presenting with headache are questioned about their non-prescription analgesic use. Many people will have tried over the counter NSAIDS or paracetamol (and now perhaps sumatriptan) prior to a consultation. A history of self management is often useful in determining the type of headache and the treatment options.

For more information about sumatriptan and the treatment of migraine see BPJ 7.