Week 3: Glaucoma & Contraceptives Flashcards
What is the only modifiable risk factor for glaucoma?
IOP- balance between the rate of formation of aqueous humor and amount of resistance to its outflow
What is 90-95% of all primary glaucoma?
primary open angle (POAG)
Primary open angle glaucoma is ____ progressive and found in pts greater than 50 years old
slowly
What type of glaucoma is 10% of all primary cases?
primary angle closure
Why is primary angle closure treated as an emergency?
to avoid vision loss
What are the most common agents that are used in glaucoma?
beta-adrenergic blocking agents (beta blockers)
What is the MOA of beta blockers in glaucoma?
acts on beta 2 receptors in the ciliary processes which leads to reduction of aqueous humor production
How can systemic SEs be decreased when using beta blockers?
using punctual occlusion (holding lacrimal duct for 3-5 minutes)
What is the first line medication for glaucoma unless contraindicated?
beta blockers
caps are yellow or blue
What is significant about beta blocker, Betaxolol (Betopic S)?
does not lower the IOP as much as other products but has shown positive influence on visual fields
What beta blockers is the gold standard in treatment for glaucoma?
timolol solution (Timoptic)
timolol solution (Timoptic) is ______ .
non selective
timolol solution (Timoptic) gel forming solution is administered how often?
once a day
What is the MOA of adrenergic agents- sympathomimetics?
acts on both alpha and beta receptors
alpha: decrease aqueous humor production
beta: increase in outflow
What are 2 names of adrenergic agents?
epinephrine (Glaçon, Epifrin)
Dipivefrin (Propine)
What are the systemic SE of adrenergic agents?
palpitations tachycardia headache anxiety increased sweating
What medication is a prodrug of epinephrine?
Dipivefrin
What is shown to be effective in combo with Dipivefrin?
combo with non selective beta blocker for a more pronounced IOP decrease
What is the MOA of selective alpha 2 agonists?
decrease aqueous production
alpha 2 selectivity presents release of norepinephrine into the synapse which decreases aqueous humor production and increase uveoscleral outflow
What are 2 examples of selective alpha 2 agonists?
Apraclonidine (Iopidine)
Brimonidine (Alphagan
When are selective alpha 2 agonists used?
in addition to other agents, if used at all
What selective alpha 2 agonist has additional 20% decrease in IOP but tachyphylaxis develops rapidly?
Apraclonidine (Iopidine)
When are Brimonidine (Alphagan) used?
Can be used alone in patients who are intolerant to beta blockers
What is the MOA of Cholinergics?
Stimulation of the sphincter pupillae in the iris
Causes miosis(reduces amount of light entering the eye and field of vision)
pulls open the meshwork pores through ciliary muscle contraction
Increased outflow
What cholingeric reduces IOP by 20-30%?
Pilocarpine
What are 2 examples of cholinergics?
Pilocarpine
Carbachol
What cholinergic is an elliptical device placed under upper part of lower lid and replaced every week?
Ocusert-slow release delivery system
What are the cholinesterase inhibitors? MOA?
anticholinesterase agents
binds to enzyme which breaks down endogenous acetylcholine
parasympathomimetics
When are anticholinesterases used?
used only in patients unresponsive or intolerant of other therapies
What is the MOA of carbonic anhydrase inhibitors? (CAIs)
inhibit carbonic anhydrase in ciliary body to decrease aqueous formation by 40-60%
What are examples of CAIs?
Dorzolamise (Trusopt)
Acetazolamide (Diamox)
How is Dorzolamise (Trusopt) given and how much does it reduce IOP?
topical
reduce by 15-26%
How is Acetazolamide (Diamox) given? How much does it reduce IOP?
Oral
Reduce by 25-40% Higher incidence of SEs
What are the 3 medications of choice for glaucoma?
- beta blockers
- Prostaglandin F2 alpha analogues
- Carbonic Anhydrase Inhibitors (CAIs)
What is the MOA of Prostaglandlin F2 alpha analogues?
Increase uveoscleral outflow of aqueous humor
What are the SEs of Prostaglandin F2 alpha analogues?
fewer systemic effects compared to TImolol
iris pigmentation by 7-16%
eyelash thickening
How effective are Prostaglandin F2 alpha analogues at decreasing IOP?
similar to beta blockers if not more
What is an example of a Prostaglandin F2 alpha analogues?
Lantanoprost (Xalatan) solution 0.005% every 24 hours
What is the definitive treatment of angle closure glaucoma?
ER
iridectomy is the definitive treatment
How are failure rates listed?
From “best use” to “typical use”
What is the MOA of primary hormonal contraceptives?
inhibition of ovulation
What is a synthetic estrogen?
ethinyl estradiol (EE)
What are synthetic progesterone analogs? Example?
Progestins
levonorgestrel (LNG)
What are monophasic products of OCP?
packaged as 21/7 day cycles
21 days of constant E/P dose, 7 days of placebo
What are biphasic product OCPs?
2 different doses of E and or P, 7 days placebo
What are triphasic products of OCPs?
3 doses, 7 days or less of placebo
more physiologic with fewer withdrawal bleeds per year
What are quadriphonic precuts of OCPs?
4 drug doses, few or no placebo
What is the “Mini Pill”?
Progesterone only-28 active tablets
What are the benefits of Hormonal Contraceptives? (4)
Increased hemoglobin (some OCs contain iron)
Reduced risk of fetal neural tube defects (some OCs contain folate)
Decreased vasomotor symptoms in perimenopausal (hot flashes)
Increased bone mineral density in perimenopausal women
What is an adverse effect of hormonal contraceptives?
Venous thromboembolism (VTE)
What are the greatest risk factors for VTE? What hormonal contraceptive should they be given?
obesity smokers htn diabetes recent post op previous DVT **Use progestin ONLY in these pts**
What progestin has the least risk of VTE?
levonorgestrel
Hormonal contraceptives are associated with cancer and cardiovascular effects when?
mostly associated with unopposed estrogen
HOw are newer hormonal meds changed to reduce risk of cancer and CV effects?
newer combo has less EE, or contain only progesterone.
Lower EE increases risk of failure (pregnancy)
Pts taking hormonal contraceptives with HTN have an increased risk of what?
MI
stroke
What are ethinyl estradiol (EE) not recommended for pts?
smokers >35
HTN
Migraines
How can the less serious side effects be avoided with HCs?
most can be minimized or avoided by adjusting the ethinyl estradiol (EE) and/ or progestin content
How is a transdermal patch applied? What is an example?
Xulane
apple 1 patch weekly for 3 weeks
then 1 week without a patch
When is the transdermal patch less effective?
in women >90kg (198lbs)
What are the medications in a vaginal rings?
ethinyl estradiol (EE) 20mg/day etonogestrel 120mcg/day
How is the vaginal ring given?
left in place x 3 weeks
then 1 week ring free interval
How does fertility return after vaginal ring removal?
Rapid!
When using the vaginal ring users report less…..(4)
nausea
acne
irritability
depression
What are the injectable hormonal contraceptives and how are they given?
Depo-Provera: 150mg IM q 3 moths
Depo-SubQ Provera: 104mg SC Q 3 months
How do injectables compare total contraceptives?
improved adherence
What are the SE of injectable hormonal contraceptives?
decreased bone mineral density
fertility may be delayed for 6-12 months after last injection
When should injectable hormonal contraceptives be DCs to prevent decrease in bone mineral density?
after 2 years of use
What are the types of long-acting reversible contraceptives (LARC)?
subdermal implant
intrauterine device
What are the two types of intrauterine devices (IUD)?
non hormonal (Copper) Hormonal
What is the name of the subdermal implant?
Nexplanon
How long can Nexplanon be used?
3 year duration of use
What is significant about Nexplanon? (3)
contains barium for x ray visualization
not affected by BMI
Safe immediately post part or abortion
What is the duration of a copper IUD use?
10 years
What is the most effective form of emergency contraception?
Copper IUD
What is the main SE of copper IUD?
increased menstrual bleeding
What is the duration of use for a hormonal IUD?
3-5 years
How do hormonal IUDs differ from copper when it comes to bleeding?
Hormonal IUD tend to decrease heave mental bleeding
What are the IUD drawbacks? (3)
Unsuccessful in up to 18%
Risk of expulsion
Risk of uterine perforation
What is the risk of expulsion immediately post placenta delivery?
3-27%
What is the risk of expulsion 10mins to 48 hours post placenta delivery?
11-27%
What is the risk of expulsion 4-8 weeks post partum?
0-6%
What are the emergency contraception pills (ECPs)? (2)
Progestin ECPs (Levonorgestrel) Antiprogestin ECPs (Ulipristal Acetate)
What is the ingredient in progestin ECPs?
Levonorgestrel
take up to 72 hours post intercourse
What ECP is available OCT?
Progestin ECP (Levonorgestrel)
What is the active ingredient in Antiprogestin that is RX ONLY?
Ulipristal acetate (Ella) may be taken up to 5 days after intercourse
Which ECP pill is more effective?
Antiprogestin (Ulipristal acetate)
What is important to remember with ECPs?
prompt use is prudent
What is more effective than ECPs and can be inserted up to 10 days post intercourse?
Copper IUD
What medication is an abortifacients?
Mifepristone(Mifeprex, RU-486)
What is the PO version of Mifepristone(Mifeprex, RU-486)?
misoprostol (cytotec)
What is the success rate with Mifepristone(Mifeprex, RU-486)?
> 90% with pregnancies less than or equal to 49 days
ethinyl estradiol (EE) is mainly metabolized by ______.
CYP3A4
How do CYP3A4 inducers affect hormonal contraceptives?
they increase hormonal contraceptives metabolism and increase the risk of pregnancy.
What are examples of CYP3A4 inducers?
anticonvulsants
antiretrovirals (HIV meds)
Others: St John’s wort