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Systemic bioavailability of eye medications
The Journal of Emergency Medicine
i.v. push immediately effective in relieving this symptom with no significant additional sedation resulting from same. As far as other forms of dystonic reactions, none of the writers who used the doses mentioned in these reports have encountered significant extrapyramidal reactions (2,3,6,7). My experience parallels this. In summary, I applaud Bigal, Bordini, and Speciali for their impressive study of a rapid, safe and effective treatment of migraine—intravenous chlorpromazine (1). Leonard Y. Herman, MD Queen of Angels-Hollywood Presbyterian Medical Center Los Angeles, CA doi:10.1016/S0736-4679(03)00213-0
REFERENCES 1. Bigal ME, Bordini CA, Speciali JG. Intravenous chlorpromazine in the emergency department treatment of migraine: a randomized controlled trial. J Emerg Med 2002;23:14 – 8. 2. Weinberger T. Parenteral chlorpromazine for migraine [letter]. Ann Emerg Med 1984;13:750. 3. Wei M, Taylor J. Parenteral chlorpromazine for migraine [letter]. Ann Emerg Med 1984;13:750. 4. Iserson KV. Parenteral chlorpromazine treatment of migraine. Ann Emerg Med 1983;12:756 – 8. 5. Kain BF. Non-narcotic relief of acute migraine [letter]. Can Fam Physician 1982;28:2037– 8. 6. Lane PL, Ross R. Intravenous chlorpromazine—preliminary results in acute migraine. Headache 1985;25:302– 4. 7. Mariani PJ. Adverse reactions to chlorpromazine in the treatment of migraine. Ann Emerg Med 1988;17:380 –1.
e SYSTEMIC BIOAVAILABILITY OF EYE MEDICATIONS As an ophthalmologist, I read with interest the prizewinning report of apnea in a child after the application of glaucoma eyedrops (1). The message that topical eye medications can reach the systemic circulation to produce surprisingly efficacious concentrations needs special emphasis in contemporary emergency medicine practice because in the last 5 years the number of topical drugs available in ophthlamology has mushroomed. Ophthalmic topical drugs show a wide variety of extraocular side effects, from contact dermatitis with some
323
antiglaucoma agents, to systemic anticholinergic effects from atropine, to hypertension from phenylephrine, to drowsiness from agents such as the newer brimonidine. In the inherent heterogeneity of a population, the novel agents will exhibit side effects that have been poorly characterized or have remained latent during the development. As a case in point, topical beta-blockers have outstanding notoriety in ophthalmology. For example, there is a large difference in the systemic absorption of betaxolol eyedrops among elderly patients, thereby conferring a differential risk of a cardiorespiratory problem (2). During my emergency medicine career, I have seen life-threatening bradycardia and hypotension attributable to beta-blocker eyedrop use. It is sobering to appreciate that the effect on arterial blood pressure, lung function, and heart rate is similar between ordinary eyedrop exposure and intravenous administration of timolol (3). Indeed, longer-term ocular exposure to timolol changes the serum lipid profile adversely and thus can even modify a major cardiovascular risk factor (4). The emergency physician of today needs to be warned about the drug revolution in ophthalmology because less familiar and newer eyedrops may be unwittingly ignored in an acute presentation. One practical recommendation that can be given to patients to reduce systemic absorption is to apply firm digital pressure to the inner corner of the closed eye after drop installation, for about 5 s, to reduce drainage of drug to the highly vascular nasopharyngeal mucosa. Jagdeep S. Gandhi, BSc (Hons), MBChB, MRCS Ed Charing Cross Hospital London, England doi:10.1016/S0736-4679(03)00214-2
REFERENCES 1. Kwon KT, Kazzi AA. Absorption of topical ophthalmic medications presenting as lethargy and apnea in an infant. J Emerg Med 2002; 23:371– 4. 2. Vainio-Jylha E, Vuori ML, Pyykko K, Muupponen R. Plasma concentration of topically applied betaxolol in elderly glaucoma patients. J Ocul Pharmacol Ther 2001;17:207–13. 3. Korte JM, Kaila T, Saari KM. Systemic bioavilability and cardiopulmonary effects of 0.5% timolol eyedrops. Graefes Arch Clin Exp Ophthalmol 2002;240:430 –5. 4. Khamar MB, Ghatt N, Patel N. Serum lipid profile and timolol gel. J Indian Med Assoc 2002;100:620 –1.
i.v. push immediately effective in relieving this symptom with no significant additional sedation resulting from same. As far as other forms of dystonic reactions, none of the writers who used the doses mentioned in these reports have encountered significant extrapyramidal reactions (2,3,6,7). My experience parallels this. In summary, I applaud Bigal, Bordini, and Speciali for their impressive study of a rapid, safe and effective treatment of migraine—intravenous chlorpromazine (1). Leonard Y. Herman, MD Queen of Angels-Hollywood Presbyterian Medical Center Los Angeles, CA doi:10.1016/S0736-4679(03)00213-0
REFERENCES 1. Bigal ME, Bordini CA, Speciali JG. Intravenous chlorpromazine in the emergency department treatment of migraine: a randomized controlled trial. J Emerg Med 2002;23:14 – 8. 2. Weinberger T. Parenteral chlorpromazine for migraine [letter]. Ann Emerg Med 1984;13:750. 3. Wei M, Taylor J. Parenteral chlorpromazine for migraine [letter]. Ann Emerg Med 1984;13:750. 4. Iserson KV. Parenteral chlorpromazine treatment of migraine. Ann Emerg Med 1983;12:756 – 8. 5. Kain BF. Non-narcotic relief of acute migraine [letter]. Can Fam Physician 1982;28:2037– 8. 6. Lane PL, Ross R. Intravenous chlorpromazine—preliminary results in acute migraine. Headache 1985;25:302– 4. 7. Mariani PJ. Adverse reactions to chlorpromazine in the treatment of migraine. Ann Emerg Med 1988;17:380 –1.
e SYSTEMIC BIOAVAILABILITY OF EYE MEDICATIONS As an ophthalmologist, I read with interest the prizewinning report of apnea in a child after the application of glaucoma eyedrops (1). The message that topical eye medications can reach the systemic circulation to produce surprisingly efficacious concentrations needs special emphasis in contemporary emergency medicine practice because in the last 5 years the number of topical drugs available in ophthlamology has mushroomed. Ophthalmic topical drugs show a wide variety of extraocular side effects, from contact dermatitis with some
323
antiglaucoma agents, to systemic anticholinergic effects from atropine, to hypertension from phenylephrine, to drowsiness from agents such as the newer brimonidine. In the inherent heterogeneity of a population, the novel agents will exhibit side effects that have been poorly characterized or have remained latent during the development. As a case in point, topical beta-blockers have outstanding notoriety in ophthalmology. For example, there is a large difference in the systemic absorption of betaxolol eyedrops among elderly patients, thereby conferring a differential risk of a cardiorespiratory problem (2). During my emergency medicine career, I have seen life-threatening bradycardia and hypotension attributable to beta-blocker eyedrop use. It is sobering to appreciate that the effect on arterial blood pressure, lung function, and heart rate is similar between ordinary eyedrop exposure and intravenous administration of timolol (3). Indeed, longer-term ocular exposure to timolol changes the serum lipid profile adversely and thus can even modify a major cardiovascular risk factor (4). The emergency physician of today needs to be warned about the drug revolution in ophthalmology because less familiar and newer eyedrops may be unwittingly ignored in an acute presentation. One practical recommendation that can be given to patients to reduce systemic absorption is to apply firm digital pressure to the inner corner of the closed eye after drop installation, for about 5 s, to reduce drainage of drug to the highly vascular nasopharyngeal mucosa. Jagdeep S. Gandhi, BSc (Hons), MBChB, MRCS Ed Charing Cross Hospital London, England doi:10.1016/S0736-4679(03)00214-2
REFERENCES 1. Kwon KT, Kazzi AA. Absorption of topical ophthalmic medications presenting as lethargy and apnea in an infant. J Emerg Med 2002; 23:371– 4. 2. Vainio-Jylha E, Vuori ML, Pyykko K, Muupponen R. Plasma concentration of topically applied betaxolol in elderly glaucoma patients. J Ocul Pharmacol Ther 2001;17:207–13. 3. Korte JM, Kaila T, Saari KM. Systemic bioavilability and cardiopulmonary effects of 0.5% timolol eyedrops. Graefes Arch Clin Exp Ophthalmol 2002;240:430 –5. 4. Khamar MB, Ghatt N, Patel N. Serum lipid profile and timolol gel. J Indian Med Assoc 2002;100:620 –1.