AED - Anti-inflammatory Agents I - Week 6

Question 1

List 7 kinds of anti-inflammatory agents used in Australia and give an example for each.

Answer 1

Astringents - zince sulphate
Anti-histamines - antazoline
MCS - lodoxamide
Dual action MCS/AH - olopatadine
NSAIDs - ibuprofen
Corticosteroids - dexmethasone
Calcineurin/T-cell inhibitor - cyclosporine

Question 2

Consider topical steroids. What is its potency and corneal penetration dependent on?

Answer 2

The formulation used - acetate vs phosphate vs alcohol

Question 3

What kind of potency and penetration is ok for mild surface inflammation? What does this formulation minimise?

Answer 3

Low potency, low penetration
Minimises chance of steroid-induced IOP rise

Question 4

High penetration and potency is essential for what eye disease? What formulation specifically?

Answer 4

Anterior uveitis
If required, write acetate on the Rx

Question 5

Order the following by penetrance from highest to lowest:
Alcohol
Phosphate
Acetate

Answer 5

Acetate&raquo_space; alcohol > phosphate

Question 6

What is the general guideline for the use of ocular lubricants (4)?

Answer 6

Mild ocular surface irritation (including SPK)
Neurotrophic keratitis
Adjunct in severe inflammation

Question 7

What is the general guideline for the use of astringent eye drops (1)?

Answer 7

Mucoid discharge in allergic surface disease

Question 8

What is the general guideline for the use of antihistamine eye drops (1)?

Answer 8

Allergic eye disease (type I hypersensitivity)

Question 9

What is the general guideline for the use of MCS eye drops (1)?

Answer 9

Allergic eye disease (type I hypelsensitivity)

Question 10

What is the general guideline for the use of dual action MCS/AH eye drops (1)?

Answer 10

Allergic eye disease (type I hypersensitivity)

Question 11

What is the general guideline for the use of NSAIDs for ocular conditions (5)?

Answer 11

Mild/moderate allergic eye disease and other surface inflammation (episcleritis)
Intra-operative inhibition of miosis
Post-operative inflammation/analgaesia

Question 12

What is the general guideline for the use of corticosteroid eye drops (5)?

Answer 12

All types of moderate to severe ocular surface inflammation
HSV and HZO keratitis (not epithelial)
Anterior uveitis
Endophthalmitis (intravitreal)

Question 13

What is the general guideline for the use of cyclosporine eye drops (5)?

Answer 13

Corneal graft
Uveitis
Scleritis
VKC
Dry eye

Question 14

Are astringents safe in pregnancy, lactation, and children?

Answer 14

Yes to all three

Question 15

Are antihistamines safe in pregnancy, lactation, and children?

Answer 15

Avoid use in pregnancy and lactation
Children are probably ok

Question 16

Are MCS safe in pregnancy, lactation, and children?

Answer 16

Probably safe in all three

Question 17

Are dual action MCS/AH safe in pregnancy, lactation, and children?

Answer 17

Probably safe in all three

Question 18

Are NSAIDs safe in pregnancy, lactation, and children?

Answer 18

Caution/not recommended in pregnancy
Safe in lactation and children

Question 19

Is cyclosporine safe in pregnancy, lactation, and children?

Answer 19

Caution/not recommended in pregnancy
Contraindicated in lactation

Question 20

Are steroids safe in pregnancy, lactation, and children?

Answer 20

Safe in pregnancy and lactation
Not established in children

Question 21

What strength of steroid should pregnant women be prescribed?

Answer 21

The lowest potency required

Question 22

Why does prednisolone need to be shaken before use?

Answer 22

Acetate form is a suspension

Question 23

What is prednisolone used in the management of?

Answer 23

Uveitis

Question 24

Does prednisolone have low, moderate, or high strength?

Answer 24

High strength

Question 25

What formulation is prednisolone?

Answer 25

Acetate

Question 26

Compare fluoromethalones to prednisolone in terms of effectivity and IOP.

Answer 26

Fluoromethalones have less of an IOP spike but less effective than prednisolone

Question 27

What is a good rule of thumb when considering oral vs topical.

Answer 27

If inflammation no deeper than the iris / anterior ciliary body, topical therapy may be appropriate

Question 28

What is a general guideline if the iris or anterior ciliary body need to be targeted?

Answer 28

Better penetrance is required and more frequent administration may be needed for therapeutic dose

Question 29

What is a general guideline if structures deeper than the iris / anterior ciliary body need to be targeted (4)?

Answer 29

Oral / intraocular / sub-conj. / sub-Tenon’s injection may be required

Question 30

List 5 potential side effects of short-medium term steroid doses.

Answer 30

IOP spike Secondary/reactivation of infection Masking clinical signs Delayed wound healing Transient discomfort

Question 31

List 2 potential side effects of long term steroid doses. Give percentages where possible (2).

Answer 31

IOP rise Cataract - mainly posterior subcapsular -33% after 12 months -52% after 24 months

Question 32

List 5 mechanisms of action of glucocorticoids.

Answer 32

Blocks phospholipase A2 activity, decreasing cytokine produnction Decreases cellular response Prevents mast cell degranulation Deregulates cellular DNA expression Suppresses adrenal secretions of steroids

Question 33

Give 4 reasons why we wouls suppress inflammation.

Answer 33

It may lead to cell/tissue loss May lead to scarring and loss of function May lead to collateral ocular surface disturbance Improved patient comfort and surgical outcome

Question 34

In how many days can peak steroid IOP response occur?

Answer 34

As little as 6 days

Question 35

Define Cushing's syndrome.

Answer 35

Too much steroid

Question 36

What can occur in the eye with the use of NSAIDs (diclofenac specifically)?

Answer 36

Stromal lysis

Question 37

Can long-term steroid use be abruptly stopped?

Answer 37

No, it must be tapered

Question 38

Does stadard topical therapy using steroids require tapering?

Answer 38

Yes

Question 39

Does occasional short term / low dose steroid use require tapering?

Answer 39

No

Question 40

Why must steroid use sometimes be tapered?

Answer 40

With steroid use, natural cortisol levels decrease If abruptly stopped, there is a delayed body response in which natural cortisol levels are low, which promotes rebound inflammation

Question 41

What is meant by pulse-dose?

Answer 41

High dose short bursts produce, which quicker therapeutic effect with shorter-lived side-effects

Question 42

In the eye, what is pulse dosing typically used for (2) and not used for (2)?

Answer 42

Commonly used in allergic / contact conjunctivitis Not used in uveitis or HZO

Question 43

One requires caution when pulse-dosing?

Answer 43

The drug's toxicity profile

Question 44

Consider a true allergic eye disease (type I). Is it immediate or delayed on second exposure to the allergen?

Answer 44

Immediate

Question 45

Consider delayed hypersensitivity (type IV). Can it be managed with MCS/AH?

Answer 45

No, need steroids

Question 46

Consider ocular inflammation due to topical drugs. Describe its occurence by type and percentage. Can the different types be told apart?

Answer 46

90% are due to direct toxicity 10% are a delayed immune response

Question 47

Do anti-histamines help with redness as well as itching? Explain.

Answer 47

no, just itching as its only a H1 antagonist

Question 48

What should be managed before treating for inflammation and why?

Answer 48

Steroids completely block the body’s natural defences against infection Manage active infection before associated inflammation