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OD2 Semester 2 - Applied Clinical Training > wk8: AED - Anti-inflammatories [DG] > Flashcards

wk8: AED - Anti-inflammatories [DG] Flashcards

1
Q

What are the 7 categories of anti-inflammatories in Australia? Provide an example for each category

A 
Astringents - zinc sulphate
Anti-histamines - levocabastine
MCS - sodium cromoglycate
Dual action MCS/AH - olopatadine
NSAIDS - diclofenac
Corticosteroids - fluoromethalone
Calcineurin/T-cell inhibitor - cyclosporine (not available in aus.)
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2
Q

How do astringents work?

A

break down mucus production, reduce leakiness

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3
Q

How long do MCSs take to start working? Knowing this, what do we clinicians like to do?

A

2-4 week period. So we like to use dual action MCS/Anti-histamines like patanol or zatadin 2 x day

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4
Q

List the topical multi-use (preserved) eye drops available in Australia (5)

A 
all anti-histamines
all MCSs
all dual action MCS/AHs
all NSAIDS
all corticosteroids (except prednisolone phosphate)
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5
Q

List the topical single-use (non-preserved) eye drops available in Australia (5)

A 
most lubricant bases
phenylephrine (in albalon relief)
ketotifen (zatiden single dose)
flurbiprofen (in ocufen)
prednisolone phosphate (minims)
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6
Q

List the topical eye ointments available in Australia (2)

A

lubricants (but as paraffin)

hydrocortisone

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7
Q

How do topical steroid formulations differ? (2)

A

different potencies

different corneal penetration

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8
Q

What type of inflammation is low potency, low penetration steroids good for? Why?

A

ok for mild surface inflammation (minimises chances of steroid-induced pressure rise)

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9
Q

When are high potency, high penetrative steroids essential? If they are required, what should you write on the Rx?

A

for anterior uveitis. If this level of steroid is required, write ACETATE on the Rx

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10
Q

Which has the greater corneal penetrance: alcohol based steroids or acetate based steroids?

A

acetate based steroids

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11
Q

What is the treatment goal for inflammation?

A

Rapid control of inflammation to minimize complications (drug and disease)

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12
Q

What is a “loading dose”?

A

an initial higher dose of a drug that may be given at the beginning of a course of treatment before dropping down to a lower maintenance dose.

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13
Q

Is a loading dose always required for steroid use?

A

Some argue for some argue against it. Though you honestly don’t have to reach therapeutic window as fast as antibiotics (because you don’t have to deal with exponentially dividing bacteria). Darryl Guest - “I don’t think loading dose matters too much for steroids”

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14
Q

Do you use a loading dose for antibiotics? And if so, do you finish the course early or go through the entire course of antibiotics?

A

Yes. Still go through the whole course

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15
Q

How does steroid potency differ from antibiotic potency?

A

Different steroids vary in potency. Different antibiotics don’t vary in potency because potency is determined by what you are trying to kill

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16
Q

What are the 3 levels of lists on the OBA website for optometry drugs

A
  1. Drugs you are allowed to use
  2. TGA list - what’s available
  3. PBS list - what’s subsidised
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17
Q

Name 6-8 anti-inflammatories found in the OBA

A 
Cyclosporin
Dexamethasone
Diclofenac
Fluoromethalone
Flurbiprofen
Hydrocortisone
Ketorolac
Prednisolone
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18
Q

For a steroid to have an adequate effect in the anterior chamber, what 2 things will it need?

A

Needs both potency and penetration

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19
Q

Describe the following drugs for their potency, penetration and capacity to raise IOP (when in ant. chamber):

  • Hydrocortisone alcohol
  • Hydrocortisone acetate
  • Flouromethalone alcohol
A

Potency Penetr. IOP
Hy.Al v. low - ++
Hy.Ac low ++ ++
Fl. Al. mid - +++

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20
Q

Describe the following drugs for their potency, penetration and capacity to raise IOP (when in ant. chamber):

  • prednisolone phosphate
  • fluorometholone acetate
  • prednisolone acetate
  • dexamethasone alcohol
A 
poten. pen. IOP
Pr.Ph  mid    +       +++
Fl.Ac   high   ++    +++
Pr.Ac.  high  +++  ++++
D.Al     high  ++    ++++
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21
Q

How do acetates, alcohols and phosphate steroids compare in terms of penetration? Rank them from highest penetrance to lowest

A

acetate&raquo_space; alcohol > phosphate

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22
Q

What are the 2 main side effects of steroid use? Give an example of a patient where one of these side effects won’t be a concern

A

increase in IOP
increase risk of steroid cataract
- note: patients who have already had cataract surgery and are wearing IOLs will not have to worry about the cataract side effect

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23
Q

As a general guideline for anti-inflammatory usage:

- What should ocular lubricants be used for? (4)

A

mild ocular surface irritation (inc. SPK)
dry eye
neurotrophic keratitis
adjunct in severe inflammation

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24
Q

As a general guideline for anti-inflammatory usage:

  • What should astringents be used for? (1)
  • what is a limitation of astringents? (1)
A

mucoid discharge in allergic surface disease

but not as readily available as other options

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25
Q

As a general guideline for anti-inflammatory usage:

  • What should anti-histamines be used for? (1)
  • What should MCSs be used for? (1)
  • What should dual action MCS/AH be used for?(1)
A

All 3 of these are used for allergic eye disease (type 1 hypersensitivity)

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26
Q

As a general guideline for anti-inflammatory usage:

- What should NSAIDs be used for? (5)

A

mild/moderate allergic eye disease
other surface inflammation (e.g. epicleritis)
intra-operative inhibition of miosis
post-operative inflammation/analgesia
“my main use is cystic oedema associated with cataract surgery” - Darryl Guest

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27
Q

As a general guideline for anti-inflammatory usage:

- What should corticosteroids be used for? (4)

A

all types of moderate-severe ocular surface inflammation
HSV and HZO keratitis (NOT epithelial)
anterior uveitis
endophthalmitis (intravitreal)

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28
Q

As a general guideline for anti-inflammatory usage:

- what should cyclosporine be used for? (5)

A 
corneal graft
uveitis
scleritis
VKC
dry eye
29
Q

As a general guideline for anti-inflammatory usage, How safe are the following drugs in pregnancy?

  • Astringents
  • Anti-histamines
  • MCSs
A

Astringents: safe
Anti-histamines: avoid (probably ok in kids)
MCS: cromoglycate safe, lodoxaimde uncertain (both safe lactation/kids)

30
Q

As a general guideline for anti-inflammatory usage, How safe are the following drugs in pregnancy?

  • dual action MCS/AH
  • NSAIDs
  • Cyclosporin
A

dual action: same as antihistamines (avoid preg, lac. kids ok)
NSAIDs: caution/not recommended (safe in lactation/kids)
Cyclosporin: caution/not reccommended (contraind. in lac)

31
Q

Are steroids safe in pregnancy? Explain

A

Controversial. Differing opinions from different studies. Manufacturers say no so they don’t get sued. But in some cases benefits may outweigh risks

32
Q

You have a pregnant patient with iritis and are considering steroids but they are pregnant. What should you do to best manage this patient? (2)

A

Be up to date with literature (literature surrounding this may change)
Engage in conversation with px

33
Q

When given multiple drops of steroids, how long should the time gap be between the drops?

A

Minimum 5 minutes

34
Q

In regards to prednisolone:

- describe its characteristics (2)

A

Ketone based

highly efficacious

35
Q

In regards to prednisolone:

- what is different about its acetate form? (1.5)

A

acetate form is a suspension, so you’ll have to shake the bottle

36
Q

In regards to prednisolone:

- What do we use it for? (2)

A

significant inflammation

uveitis mx

37
Q

How strong are fluoromethalones?

A

moderate strength

38
Q

What are the 2 forms of fluoromethalones?

A

Alcohol form = FML and Flucon

Acetate form = Flarex

39
Q

How does the effect of fluorometholones compare to pred forte? (2)

A

Less of an IOP spike but less effective than pred forte.

40
Q

How does steroid anti-inflammatory treatment change based on whether the inflammation is at the iris/ciliary body or deeper than the iris/ciliary body? (4)

A

At iris/cil.body: topical therapy may be appropriate; better penetrance or more frequent admin may be needed for therapeutic dose

Deeper (or not controlled by topical): oral or intraocular/sub conj./sub-Tenon’ injection may be required

41
Q

List the short-medium term dose potential side effects of steroids (5)

A 
IOP spike
secondary/reactivation of infection
masking clinical signs
delayed wound healing
transient discomfort
42
Q

What type of infections are likely to reinfect if using steroids for short-medium term? (3)

A

zosta type infections
simplex infections
pseudomonas

**so basically don’t use steroids for these

43
Q

Is delayed wound healing from steroid use a big deal?

A

not particularly. May only slow 15-20% and the benefits often outweigh this downside

44
Q

List the potential side effects from long term dose steroids (2)

A

IOP rise

Cataract - mainly posterior subcapsular

45
Q

What percentage of patients get cataracts after 12 months of steroid use? What about 24 months?

A

12 months: 33%

24 months: 52%

46
Q

What would you consider a critical IOP rise in a young person after short term steroid use? Why?

A

Start to worry at about 28-30 IOP. Because at this IOP we start to risk central retinal vein occlusion. If diastolic blood pressure in the eye is lower than IOP, the blood won’t flow, hence occlusion.

(note: blood pressure in the eye is different from rest of body)

47
Q

List the different actions of glucocorticoids (5)

A

Block phospholipase A2 activity – decrease infl. cytokine prod.
Decrease cellular response and macrophages
Prevent mast cell degranulation
Deregulate cellular DNA expression
Suppress adrenal secretions of steroids (takes one week)

48
Q

How ong do adrenal secretions of steroids take to come back when glucocorticoids are removed?

A

about 3-5 weeks

49
Q

What is the average drop size of a topical steroid compared to our tear volume? Knowing this, how much of the drop is lost on administration?

A

avg. drop size = 50ul
tear vol = 30ul

So like 30ul of the drop is lost. I.e. most of the drop is lost immediately

50
Q

When administering prednisolone (in a rabbit study), what percentage of the prednisolone can you expect to reach the cornea? aqueous?

A

Cornea - 1.7%

Aqueuous - 0.1%

51
Q

Why suppress inflammation? (4)

A

May lead to cell/tissue loss (e.g. bacterial keratitis, necrotic hsv keratitis)
May lead to scarring + loss of function (e.g. microbial keratitis, stromal hsv keratitis, synechiae in ant. uveitis)
May lead to collateral ocular surface disturbance (e.g. GPC, VKC)
Improved px comfort, improved surgical outcome

52
Q

What are the potential ocular downsides to anti-inflammatory steroids? (5)

A 
cataract
glaucoma
HSV
fungal/acanhamoebal potentiation
accelerated tissue loss (MMPs)
53
Q

What are the potential systemic downsides to anti-inflammatory steroids? (3.5)

A

Cushing’s syndrome (obesity, gastric ulcers, osteoporosis skin changes)

54
Q

What are the potential downsides of NSAIDs? (2)

A

stromal lysis from diclofenac

increased risk of post refractive surgery infections

55
Q

What are the indications for anti-inflammatory prophylaxis? (2)

A

very few:

  • pre-operative (e.g. px H/O uveitis about to undergo intraocular sx)
  • Mx of Px with H/O seasonal allergic eye disease
56
Q

Do short term/low dose steroids require tapering?

57
Q

What level of dose of steroid should you use?

A

Dose should be sufficient to control inflammation and continue as long as necessary. Appropriate dose must be re-evaluated at regular intervals

58
Q

How much can you decrease marked corneal inflammation by with 18 hours of intense steroid application?

59
Q

Should we taper long-term/high dosage steroids?

A

Yes we should

60
Q

Why should we taper steroids? (1)

A

To give the body time to adjust and produce more natural cortisol again to prevent rebound inflammation

(b/c while delivering synthetic steroid, the body starts producing less cortisol because it doesn’t need it)

61
Q

What does “pulse-dose” mean?

A

usually assoc. with systemic admin - high dose short bursts produce quicker therapeutic effect with shorter-lived side effects

62
Q

What does “pulse-dose” mean in the context of topical administration?

A

usually involves delivery at greatly increased frequency than rapid withdrawal (with no or limited taper)

63
Q

What is pulse-dose topical administration of steroids typically used for? (1.5)

A

allergic/contact conjunctivitis

64
Q

What must you NOT use pulse-dose topical administration of steroids for? (2)

A

uveitis or HZO

65
Q

Biologically, what does ocular pulse-dosing achieve? (4)

A

increases bioavailability
achieves faster inflammatory control
minimal rebound effect
reduces duration side effects

66
Q

Provide 5 examples for conditions that lend to pulse dosing

A 
non-specific ocular surface
dry eye 
help symptoms in adenoviral
SAC
GPC
67
Q

How can you usually manage type 1 allergic eye disease?

A

MCS and AH

68
Q

How can you manage type IV delayed hypersensitivity responses? (1)

A

Need steroid

69
Q

Is a steroid necessary to tx toxicity?

A

it might be

OD2 Semester 2 - Applied Clinical Training (63 decks)

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