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Ophthalmologic Indications for Compounded Medications: A Personal Perspective from Dr. Bob Murtaugh

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The following blog is written by Epicur Pharma’s Advisory Council member Bob Murtaugh, DVM, MS, DACVIM, DACVECC. He shares his insights on why compounded medications better support the successful management of ophthalmic diseases within pets.

From Bob:

Compounded medications are critical to the successful management of diseases involving the eye in veterinary patients. Below we take a deeper look at this through the illustrated relation to the availability of various formulations of cyclosporine and tacrolimus for the treatment of KCS.

The diagnosis of Keratoconjunctivitis Sicca (KCS) or “dry eye” is made based on a combination of clinical signs and tear testing. In dogs, the best method for diagnosing KCS is the use of the Schirmer tear test (STT; Type 1 – without use of topical anesthetic):

  • < 5 mm/60 sec – diagnostic
  • 5-10 mm/60 sec suspicious, retest

If tear production is in the marginal or suspicious zone the ventral corneal may appear normal, consider use of the diagnostic test Rose Bengal Staining (uptake indicates devitalization of corneal epithelium consistent with KCS) and possibly use the Schirmer Type 2 tear test (STT following application of topical anesthesia):

  • Application of a topical anesthetic ordinarily decreases STT by 40-50%.
  • In early or suspicious KCS, the decrease is more dramatic.

Initial treatment of acute KCS should involve identifying and treating the primary underlying cause and the use of artificial tears, 4-6 times a day; ideally, artificial tears that contain hyaluronic acid are used. Treatment of chronic KCS, especially those suspected to be immune-mediated, should include the use of a calcineurin inhibitor such as Cyclosporine or Tacrolimus.

Topical Cyclosporine

  • T-cell inhibitor whose therapeutic effect increases tear production by an unknown mechanism and by a beneficial effect on corneal pigmentation and excessive mucus production.
  • Initially start with 0.2% ointment (Optimmune; ¼ inch strip twice daily)
  • Use compounded 1-2% solutions in olive oil or corn oil if the response to 0.2% ointment diminishes with time.
  • Pre-existing Schirmer tear test of “0” mm wetting at 60 sec is a risk factor for non-responsiveness (i.e., lacrimal glands have been totally destroyed)
  • Lifelong therapy is almost always required and discontinuing therapy typically results in rapid drop in tear production.
  • Cyclosporine can be used if a corneal ulcer is present.

Topical Tacrolimus

  • T-cell inhibitor similar to cyclosporine.
  • Available only as a compounded formulation of 0.03% solution in oil.
  • May be useful in KCS cases that don’t respond to or stop responding to cyclosporine.
  • Can also be used for treatment of other immune-mediated ocular conditions such as chronic superficial keratitis.

Reliability for prescribing these compounded drugs – or any manufactured medications – as it relates to safety and efficacy, requires a partnership with a licensed 503A and 503B compounding pharmacy that can supply patient-specific scripts, as well as bulk office stock of these critically important ocular formulations. Of course, turn-around time and customer service should also weigh heavily in the selection of the compounding and drug manufacturing resource you partner with.

Thank you so much for sharing this important information, Dr. Murtaugh! As Bob shared, partnering with a licensed compounding pharmacy is crucial for keeping medications stocked and available for your patients. At Epicur, we make it fast and easy to order 503B medications, ready to ship the same day. Take a look at our full product portfolio and give us a call when you are ready to place your order.

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