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Ocular Pharm > Ocular Pharm: L11: Oral and IV Corticosteroids for Ocular Disorder > Flashcards

Ocular Pharm: L11: Oral and IV Corticosteroids for Ocular Disorder Flashcards

1
Q

Types of Corticosteroids

  1. Mineralocorticoids
    a. Produced in what area of the ADRENAL CORTEX?
    b. Where are receptors found?
    c. What do they control?
  2. Glucocorticoids
    a. Produced in what area of the Adrenal Cortex?
  3. The steroid drugs that we use are in which class?
A
  1. a. in the Outer Zone (Zona Glomerulosa)
    b. in Excretory Organs
    c. Water and Electrolytes
  2. a. Middle Zone (Zona Fasciculata)
  3. Glucocorticoids
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2
Q

Glucocorticoids

  1. The Primary natural species is what?
  2. Receptors are what?
  3. Activity is what?
  4. What kind of Feedback do they have on the Adrenal Gland and Hypothalamus?
A
  1. is CORTISOL
  2. UBIQUITOUS
  3. PLEOTROPIC
  4. Negative Feedback
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3
Q

Actions of Glucocorticoids

  1. What do they Promote?
  2. they Increase resistance to what?
    a. By increasing what 2 things?
  3. They Alter Blood Cell Levels in Plasma
    a. What happens?
  4. What kind of Inflammatory Activity do they have?
  5. They Decrease the production of what?
  6. Can affect what systems?
  7. The steroid drugs that we use will also have what?
A
  1. Gluconeogenesis
  2. to Stress
    a. Increased Glucose and Increase in Blood Pressure (via constriction of small vessels)
  3. a. DECREASE Most White Cells (compromises ability to fight infection) (Increase Erythrocytes, Hemoglobin, Platelets, and Neutrophils)
  4. Anti-Inflammatory Activity
  5. of TSH (thru cortisol feedback inhibition)
  6. many other systems
  7. Will also have these effects!
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4
Q

Anti-Inflammatory Effects

  1. Disruption of what?
    a. Reduces what?
    b. Prevents production of what?
  2. Reduction of Pain as a consequence of what?
  3. Is there a direct affect on infection?
    a. GENERALLY used for what types of DISORDERS?
    b. If used in the other type of disorders, what should also be given?
A
  1. of the Inflammatory Cascade
    a. existing Inflammatory Mediatiors
    b. of additional Inflammatory Mediators
  2. of Reduced Inflammation
  3. NO.
    a. for STERILE (non-infectious) disorders
    b. if used when infection is or may be present, ANTI-Infective Meds should also be GIVEN!
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5
Q

Steroids and the Inflammatory Cascade

  1. When tissue damage occurs, what is Inhibited by Corticosteroids?
A
  1. the production of Phospholipase A2
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6
Q

Routes of Steroid Administration

  1. Multiple…
  2. Which ones are we talking about mainly?
  3. Applications for Oral and Parenteral Administration
  4. Bioavailability is what?
A
  1. Topical, Intravitreal, Intralesional, Parenteral (IV), ORAL.
  2. IV and ORAL
  3. Refractory Ant. Segment Disorders, Posterior Segment Disorders, and Systemic Disorders that affect the eye.
  4. Is HIGH for ORAL CORTICOSTEROIDS
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7
Q

Commonly Used Oral Steroids

7 of them.

  • = most commonly used.
A
  1. Budesonide
  2. Cortisone
  3. Dexamethasone (DexPak 6,10,13)
  4. Hydrocortisone (Cortef)
  5. Methylprednisolone (Medrol, DosePac)*
  6. Prednisolone (Orapred, Prelone)*
  7. Prednisone (Rayos)*
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8
Q

Commonly Used IV Steroids

What 3?

A
  1. Cortisol (Hydrocortisone Sodium Phosphate)*
  2. Dexamethasone Sodium Phosphate (Decadron)
  3. Methylprednisolone (Solu-Medrol)*
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9
Q

Duration of Action

  1. What 2 are Short acting? (1-12 hrs)
  2. What 4 are Intermediate Acting (12-36 hrs)
  3. What 2 are Long Acting (36-55hrs)
  4. Which 3 DO NOT have a Salt-Retaining Effect?
A
  1. a. Hydrocortisone
    b. Cortisone
  2. a. Prednisone
    b. Prednisolone
    c. Methylprednisolone
    d. Triamcinolone
  3. a. Betamethasone
    b. Dexamethasone
  4. a. Triamcinolone
    b. Betamethasone
    c. Dexamethasone
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10
Q

Serious Side Effects

*List a few

A
  1. Allergic Reaction
  2. Glaucoma, Cataracts
  3. Fluid and Electrolyte Handling Alterations (Edema, Low Potassium, Hypertension)
  4. Severe Depression, Psychosis, restlessness and insomnia, seizures
  5. Peptic Ulcer
  6. Pancreatitis
  7. Osteoporosis/Osteonecrosis
  8. Hyperglycemia
  9. Myopathy/Muscle Wasting
  10. Growth Retardation (in children)
  11. Increased Fetal Death or Malformation (in Pregnant Women)
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11
Q

Mild Side Effects

What are they?

A
  1. Sleep Problems, restlessness
  2. Mood changes
  3. Acne, dry skin, bruising, etc.
  4. Slow wound healing
  5. Increased sweating
  6. Headache, dizziness, spinning sensation
  7. Nausea, stomach pain, bloating
  8. Changes in the shape or location of body fat (esp in arms, legs, face, neck, breasts and waists)
  9. Increased appetite
  10. Dysmenorrhea
  11. Hirsutism
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12
Q

Contraindications

What are they?

A
  1. Liver and Kidney disease
  2. Thyroid disorder
  3. Diabetes
  4. History of Malaria (can unmask infection)
  5. Tb, Osteoporosis

MG

Glaucoma or Cataracts

Herpes infection of the eyes

Stomach ulcers

Depression or mental illness

Congestive heart Failure

High Blood Pressure

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13
Q

Common Drug Interactions

  1. Lots of them (AAAA BLM NO)
A

Anticholinesterases

Anticoagulants

Anticonvulsants

Anti-Diabetics

Bronchodilators

Live Vaccines

Macrolide Antibiotics

NSAIDs

Oral Contraceptives and other Estrogens

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14
Q

Monitoring

  1. What things should be monitored?
A
  1. Hyperglycemia
  2. Glycosuria
  3. Sodium Retention with Edema or Hypertension
  4. Hypokalemia
  5. Peptic Ulcer
  6. Osteoporosis (Rx Vit D Supplements)
  7. Infections
  8. Interactions with other Drugs
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15
Q

Monitoring Schedule for Long-Term Treatment-1

  1. Baseline Physical Investigations?
  2. Bone Health (Adults)
    a. What should be done yearly?
    b. What should be done 1 year post GC start?
    i. If stable?
    ii. If decreased?

c. What should be done for adults greater than or equal to 65 yrs?
d. Use what to examine fracture risk?

A
  1. Weight, Height, BMI, BP, CBC, Glucose, Lipids, BMD
  2. a. Height measurement, and questionnaire for incident fragility fracture
    b. BMD
    i. Assess every 2-3 years
    ii. assess annually
    c. Lateral Spine X-ray
    d. use FRAX
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16
Q

Monitoring Schedule for Long-Term Treatment-2

  1. Bone Health (children)
    a. Consider a Baseline what?
    b. Repeat at intervals of what?
    c. Referral to pediatric bone health specialist if there’s evidence of what?
  2. Growth (Children and Adolescents)
    a. Monitor how often?
    b. If Growth velocity is inadequate, refer to whom?
  3. Dyslipidemia and CV Risk (Adults)
    a. Assess lipids when after GC initiation?
    b. Assess 10-year CV risk using what?
A
  1. a. spine BMD and lateral Spine x-ray in children receiving more than 3 months of GC therapy
    b. Yearly (back pain, cushing features, growth deceleration, etc)
    c. of Bone Fragility (low trauma extremity or Vertebral Fractures) or declines in BMD Z-scores
    * HPA-Axis Functioning
  2. a. every 6 months and plot on growth curve
    b. to Pediatric Endocrinologist for further assessment
  3. a. 1 month after start, then every 6-12 months
    b. using Framinham Risk Score
17
Q

Monitor Schedule for Long-Term Treatment 3

  1. Hyperglycemia/Diabetes
  2. Ophthalmologic Examination
A
  1. screen for classic symptoms at every visit: Polyuria, polydipsia, weight loss; Monitor glucose for 48 hrs after GC start, then every 3-6 months for first year, then yearly after that.
    * Children: Monitor FPG annually. (Annual OGTT if child is obese or has multiple risk factors for diabetes)
  2. Annual exam; earlier for those with cataract symptoms. Early referral for intra-ocular pressure assessment if : Personal or family history of Open Angle glaucoma, DM, Connective tissue diseases (esp. rheumatoid Arthritis)
18
Q

Withdrawal Effects

  1. Corticosteroids can suppress what?
    a. Works thru what?
    b. Abrupt withdrawal can cause what to occur?
    c. Can ABRUPT WITHDRAWAL be FATAL?
  2. Mild Euphoric Effects may trigger what?
  3. Abrupt termination may do what to the Initial Disorder?
A
  1. the Hypothalamic-Pituitary-Adrenal Axis
    a. natural feedback pathway
    b. Acute Adrenal Insufficiency Syndrome
    c. YES
  2. can trigger Dysphoria w/Abrupt Drug Termination
  3. may Exacerbate the Initial Disorder
19
Q

Short-Term Administration

  1. How long is Considered Short-term?
  2. Are adverse effects generally seen with short-term administration?
    a. What about if it’s High dosages?
  3. Is tapering of the dose required after short-term administration?
A
  1. LESS than 2 Weeks of TREATMENT
  2. No.
    a. Not usually. But CNS side effects can occur.
  3. Less tapering of the dose is required after short-term administration
20
Q

Tapering

  1. Acute Inflammation (Adult Dosing)
    a. Dose?
    b. Taper:
    i. If over 40 mg/day?
    ii. 40-20 mg/day?
    iii. 10-0 mg/day?
  2. Chronic Inflammation (Adult Dosing)
    a. Dose?
    b. Taper how?
A
  1. a. 1 mg/kg/day for 1 wk, Max Adult Oral dose 60-80 mg/DAY
    b. i. decrease dose by 10mg/day every 1-2 days
    ii. decrease dose by 5 mg/day every 1-2 days
    iii. decrease dose by 1-2.5 mg/day every 1-2 days
  2. a. 1 mg/kg/day, max adult oral dose 60-80 mg/day with a maintenance dose s done every 1-2 WEEKS
21
Q

Medrol DosePac

  1. Is has how many 4 mg tablets?
  2. Day 1?
  3. Day 2
  4. Day 3
  5. Day 4
  6. Day 5
  7. Day 6
A
  1. 21
  2. 2 tablets before breakfast, 1 after lunch, 1 after dinner, 2 at bedtime
  3. 1 before breakfast, 1 after lunch, 1 after dinner, 2 at bedtime
  4. 1 before breakfast, 1 after lunch, dinner and at bedtime
  5. 1 before breakfast, after lunch, and at bedtime
  6. 1 before breakfast and 1 at bedtime
  7. 1 before breakfast
22
Q

DexPak, TaperPak

Directions for DexPak 6-day TaperPak (21, 1.5 mg Tablets)

  1. Day 1
  2. Day 2
  3. Day 3
  4. Day 4
  5. Day 5
  6. Day 6
  7. There’s also what versions?
A
  1. 3 before breakfast and 3 after evening meal
  2. 3 before breakfast, and 2 after evening meal
  3. 2 before breakfast and 2 after dinner
  4. 2 before breakfast and 1 after dinner
  5. 1 before breakfast and 1 after dinner
  6. 1 before breakfast
  7. 10 day (35, 1.5 mg tablets), 13 day (51; 1.5 mg tablets)
23
Q

Ocular Uses of Oral Steroids

  1. Big things we use them for?
A
  1. Uveitis/Scleritis
  2. Giant Cell Arteritis
  3. Cystoid Macular Edema
  4. Sympathetic Ophthalmia
  5. Herpes Zoster (Oral steroids given w/oral antivirals decrease pain (and need for analgesics), increase sleep, and hasten return to normal daily activity)
24
Q

Anterior Uveitis

  1. Normal Symptoms?
  2. What do we normally see?
  3. Causes?
A
  1. Pain, redness, photophobia, tearing, decreased vision
  2. cells and flare in AC, Ciliary Flush, Keratic Precipitates
  3. Idiopathic, Traumatic, IOL-induced, HLA-B27 linkes, Associated w/Systemic disease (Behcet, Lyme, Sarcoidosis, Syphilis, TB)
25
Q

Anterior Uveitis Treatment

  1. Standard Treament? (3)
  2. For severe cases, or those that don’t respond to Topical Steroid treatment, what should be used?
A
  1. a. Topical Steroid
    b. Cycloplegic
    c. Manage systemic disease if present.
  2. Oral, Periocular, or Intravitreal Steroids
26
Q

Intermediate and Posterior Uveitis

  1. Intermediate
    a. Symptoms?
    b. What will we see?
  2. Posterior
    a. Symptoms?
    b. What will we see?
A
  1. a. Painless, floaters, Decreased Vision, Minimal Photophobia or External Inflammation
    b. Vitreous Cells, Snow Banking, Snow Balls
  2. a. Pain, Redness, Floaters, Blurred Vision, Minimal Photophobia
    b. Vitreous Haze and Cells, Retinal or Choroidal Inflammatory Lesions, Vasculitis
27
Q

Intermediate and Posterior Uveitis Treatment

  1. Intermediate
    a. What TOPICAL Drug?

b. What SUBTENON INJECTION?
c. What ORAL Drug and Dosage?

A
  1. a. Topical Prednisolone Acetate 1% drops q1-2 hours w/Taper at end of treatment
    b. of Triamcinolone 40 mg in 1 ml, repeated every 6-8 weeks while signs and symptoms improve
    c. Oral Prednisolone 40-60 mg qd 4-6 wks w/taper, if no improvement w/Triamcinolone.
28
Q

Scleritis

  1. What is it?
  2. Commonly associated w/what AI disorders?
A
  1. PAIN (Severe, Penetrating, Radiating). Decreased VA, REDNESS (Bluish red tinge, Localized or whole sclera). Can be Diffuse, Nodular, or Necrotizing.
  2. RA, Systemic Lupus, Spondyloarthropathies, Wegeners Granulomatosis
29
Q

Treatment of Diffuse or Nodular Scleritis

  1. What should be tried first?
  2. What if that Treatment doesn’t work?
  3. Immunosuppressive drugs added if Corticosteroids not effective. (what 3)?
  4. If therapy doesn’t work, what should you try?
A
  1. Oral NSAID or 2 Different NSAIDs in succession
  2. Oral Corticosteroids if NSAIDs not effective (Remission may be maintained w/continued NSAIDs; Periorbital and Subconjunctival Steroid Junctions as Adjunct)
  3. a. METHOTREXATE
    b. Cyclosporine
    c. Cyclophosphamide
  4. Other Immunomodulatory Drugs (e.g. Infliximab (TNFa Inhibitor))
30
Q

GCA Tx

  1. What can you give them?
    a. When should you give it to them?
    b. What should you do w/in 3 days of starting drugs?
  2. Lower dose after how long?
  3. Then slowly taper over how long?
    a. Based on what?
    b. Tapering may require how long?
A
  1. Oral or IV high-dose Prednisone (1 mg/kg/d)
    a. as soon as the diagnosis is suspected
    b. Perform a Temporal Artery Biopsy to Confirm w/in 3 Days of starting steroids.
  2. after 2-4 wks
  3. over 9-12 months
    a. on level of ESR and CRP
    b. may require 2 or more years
31
Q

Cystoid Macular Edema

  1. 4 Treatment Options
A
  1. Oral, Topical, Periocular, or Intravitreal Steroids
  2. Topical NSAIDs given w/Steroids
  3. Oral CAIs
  4. Laser or Surgery
32
Q

Sympathetic Ophthalmia (SO)

  1. Follows injury or surgery to what?
    a. What is it?
A
  1. To the fellow eye (60% w/in 2 weeks and 3 months)
    a. Diffuse, Granulomatous, nonnecrotizing, predominantly lymphocytic infiltration of the Choroid.
    * Clusters of epithelioid cells containing pigment, located b/w the RPE and Bruch’s Membrane (Dalen-Fuchs Nodules)
33
Q

Treatment of Sympathetic Ophthalmia (SO)

  1. What is the FIRST line of Treatment?
    a. May be what?
    b. What is the typical dose?
    c. How long do you treat for?
  2. What may be required?
  3. What % of cases regain VA of better than 20/40?
A
  1. Systemic Steroids
    a. Oral or IV, and May give an IV Pulse
    b. 1-1.5 mg/kg of prednisone is typical dose
    c. for at least a year w/gradual taper
  2. Immunosuppressive drugs
  3. 75%

Ocular Pharm (13 decks)

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