Corticosteroids

Question 1

While there are a plethora of indications for use of steroids, what is one contraindication?

Answer 1

epithelial herpetic infection

Also, steroid use for mis-diagnosed acanthamoeba or fungal keratitis can cause worsening of condition but are both rare

Question 2

What is an appropriate f/u time when treating with steroids?

Answer 2

no more than a couple of days

The meds should help the eye get better quickly if diagnosed correctly, but if not, the presentation will not clear and will get worse if the patient does not return quickly

Question 3

How is a typical steroid dosed?

Answer 3

Success in suppression of inflammation is selecting an appropriate steroid ad having the patient use it frequently until control is achieved followed by taper

Question 4

What are the 2 most efficacious topical ophthalmic corticosteroids?

Answer 4

Durezol emulsion and Pred Forte (NOT Pred acetate generic)

Question 5

What is Durezol? Used to treat? Dose? SE?

Answer 5

Topical steroid emulsion (no need to shake)

“BIG GUN” used to treat advanced cases of iritis and episcleritis

Long duration means less doses than Pred formulations with equal efficacy

Dosed q2h with taper
ocular inflammation/pain, postop
[1 gtt in eye(s) qid x2wk, then 1 gtt bid x1wk, then taper based on response]
Start: 24h after surgery
anterior uveitis, endogenous
[1 gtt in eye(s) qid x2wk, then taper based on response]

Risk of significant IOP elevation especially in children - MONITOR IOP

Question 6

What is Pred Forte? Used to treat? Dose?

Answer 6

Topical Prednisolone acetate 1% suspension (shake that acetate)

Tx for anterior uveitis and episcleritis and other severe inflammatory ocular conditions

DON’T LET PHARMACIST GIVE GENERIC!!! They are much less effective

[1-2 gtt in eye(s) bid-qid]
Info: may admin. more frequently for 1st 24-48h; taper dose gradually to D/C if long-term use

Question 7

What is Lotemax gel? Used to treat?

Answer 7

Non-settling gel that becomes a viscous liquid and that does not require shaking

Used as “off-label” Tx for dry eye; chronic and recurrent inflammatory conditions like stromal herpes simplex keratitis, Thygeson’s SPK, uveitis, inflamed pingueculae and pterygia. NOT AS EFFECTIVE AS PREDNISOLONE OR DUREZOL but has less SE like sub capsular cataract and increased IOP

Question 8

What is Prednisolone sodium phosphate?

Answer 8

Generic steroid solution (no shaking required) that is potent and inexpensive

Question 9

What is Prednisolone acetate? Used to treat?

Answer 9

Generic prednisolone acetate (not the same as Pred Forte)

Mild to moderate acute inflammatory conditions - especially if cost is a concern; NEVER use for advanced iritis and episcleritis

Question 10

What is Fluorometholone? Used to treat?

Answer 10

modterate/mild topical steroid aka FML; also comes as a generic, thus inexpensive

Treats moderate acute inflammatory conditions

Question 11

What is Alrex? Used to treat? Dose?

Answer 11

Moderate/mild topical steroid

Treats allergic eye disease when itching is accompanied by clinical signs of conjunctival injection, chemises or eyelid swelling

Dosed QID x 1 week; BID x 1 month

Question 12

What are the steroid ointments?

Answer 12

Lotemax, FML, Triamcinolone

Question 13

What is Lotemax ointment used to treat? Dose?

Answer 13

Ester based steroid used for post-op inflammation and pain

Off label uses: dry eye, allergy, corneal transplant protection, blepharitis, GPC, chronic uveitis, stromal immune herpetic keratitis, thygeson’s SPK, RCE, augmentation of steroid drop therapy in acute advanced uveitis or episcleritis, contact dermatitis, and other conditions that are inflammatory

apply 0.5 inch ribbon oint in eye(s) qid x2wk

Question 14

What is FML ointment used to treat? SE? Dose?

Answer 14

Used in the same way as lotemax (inflammation of palpebral and bulbar conjunctiva, cornea and anterior segment of globe including off label Txs - ost-op inflammation and pain

Off label uses: dry eye, allergy, corneal transplant protection, blepharitis, GPC, chronic uveitis, stromal immune herpetic keratitis, thygeson’s SPK, RCE, augmentation of steroid drop therapy in acute advanced uveitis or episcleritis, contact dermatitis, and other conditions that are inflammatory)

!!!!!Make sure to keep a closer watch on patient for steroid related adverse effects!!!!!

0.5 inch ribbon oint in eye(s) q4h x1-2 days, then qd-tid; Info: taper dose gradually to D/C if long-term use

Question 15

What is triamcinolone ointment used to treat? Dose?

Answer 15

aka kenalog (used in retinal injections)

Dermatologic preparation used for periocular dermatitis conditions (blepharodermatitis)

Very inexpensive

Tell patient that even though it says not for ophthalmic use, it’s fine to be used on the adnexa

Question 16

How is tapering best achieved when relapse occurs?

Answer 16

Increase dosage again but try a longer slower taper with an additional topical NSAID like bromfenac qd

Or, try oral NSAID (Celebrex) 100mg/day for a few weeks

Question 17

What kind of eye care patients are typically kept on steroids for life

Answer 17

corneal transplants, stromal immune corneal disease, chronic uveitis or recalcitrant dry eye disease

Question 18

What type of steroid is best for long-term therapy in eye care?

Answer 18

ester-based loteprednol gel qd since it has a better safety profile

Question 19

When is oral prednisone used in eye care? What is the most common dosage of oral prednisone in typical eye care? What can you do if you don’t feel comfortable prescribing oral prednisone? How is oral pred tapered?

Answer 19

Typically used after 3 day course of 1000mg IV methylprednisone for acute onset optic neuritis and GCA; hyper allergic conjunctivitis, severe contact blepharodermatitis, orbital pseudo tumor, augmentation to topical steroid therapy for severe uveitis

40mg/day (four 10mg tablets in a single daily dose)

Can range from 20-80mg/day (prescribed in half dose 2x/day)

Call patient’s PCP for consultation and “medical clearance” prior to initiation of therapy

Taper for most conditions: 40mg/day x 3-5 days then stop; or you can use a steroid dose pack that comes in 4mg, 5mg and 10mg pkgs. Ex. 5mg pack: the patient would take six tablets on day one (30mg starting dose), then reduce the dose by one 5mg tablet per day for the six-day period.

Question 20

T/F Oral prednisone should always be taken with a meal

Answer 20

True - preferably breakfast

Question 21

What are precautions for oral prednisone ?

Answer 21

Peptic ulcer disease - use OTC prevacid or prilosec (one 20mg tablet per day) or a histamine type 2 blocker like OTC Tagamet or Zantac 150mg bid; talk to PCP if unsure

Diabetes - type I: alter insulin dose on sliding scale (they should know how to do this); type II: most of pts are out of control anyway periodically and a few hyperglycemic days are not a concern in most cases; call PCP with concerns

Pregnancy: rarely used. contact OB.

TB