5. Steroids 36.pdf

Anti-Inflammatory Drugs: Steroids PharmII Steroids: Drug Delivery and Administration Diane T. Adamczyk, OD Copyright © 2024 17 17 Anti-Inflammatory Drugs: Steroids PharmII Steroid Drug Delivery Considerations Type and location of inflammation determines administration: ◦ Topical: ◦ Lids, conjunctiva...

Anti-Inflammatory Drugs: Steroids PharmII Steroids: Drug Delivery and Administration Diane T. Adamczyk, OD Copyright © 2024 17 17 Anti-Inflammatory Drugs: Steroids PharmII Steroid Drug Delivery Considerations Type and location of inflammation determines administration: ◦ Topical: ◦ Lids, conjunctiva, cornea, iris, CB ◦ Systemic or periocular (local injection): ◦ Severe anterior uveitis, chorioretinitis, optic neuritis ◦ Intracanalicular = relatively new in the last couple of years à dexamethasone has been approved for post cataract surgery ◦ Intravitreal = can be used to get to the back of the eye Diane T. Adamczyk, OD Copyright © 2024 18 Topical goes right to the area Ocular or periocular injections are used for sever -itis 18 Anti-Inflammatory Drugs: Steroids PharmII Topical Steroid Administration Indications: anterior segment disease Advantages ◦ Place where needed ◦ Simple application ◦ Uniocular disease treatment ◦ Less Systemic effects Diane T. Adamczyk, OD Copyright © 2024 19 If one eye is infected then treat the one eye so there is less potential systemic effects Steroids given systemically can throw off the whole internal steroid system 19 Anti-Inflammatory Drugs: Steroids PharmII Topical Steroid Administration Disadvantages ◦ Potential adrenal suppression ◦ >risk e.g. in children or extended use ◦ Aggravate dendritic ulcer ◦ Epithelial keratopathy ◦ Conjunctival infection Diane T. Adamczyk, OD Copyright © 2024 20 Kids are at a greater risk for even topicals including for long term use It was mentioned that kids even with topical use can be seen with it With dendritic ulcers especially epithelial the steroids can make it worse For the epithelial , the steroid can make it worse but in stroma there is an inflammatory response so need the steroid For epithelial and stromal infection (when both) treat with antiviral and steroid concurrently à epithelial needs the antiviral b/c has the virus and the stromal is having an inflammatory response so needs the steroid à wait a bit after the antiviral (a few days) to give the steroid à if you don’t use the antiviral and you use the steroid then the virus will go crazy 20 Anti-Inflammatory Drugs: Steroids PharmII Local Steroid Injection Periocular injection: ◦ Subconjunctival, sub-Tenon’s, retrobulbar ◦ Retrobulbar to sclera, choroid, retina, vitreous ◦ Last week or longer Diane T. Adamczyk, OD Copyright © 2024 21 These lasts longer when you did it this way When pts have chronic illness a sub tenon injection it can clear it up completely 21 Anti-Inflammatory Drugs: Steroids PharmII Local Steroid Injection Indications: ◦ Surgery ◦ Supplement topical and systemic steroids in severe inflammation ◦ Chalazion Diane T. Adamczyk, OD Copyright © 2024 22 Local injections can treat and manage chalazion Local injections are used for surgical procedures in addition to that 22 Anti-Inflammatory Drugs: Steroids PharmII Local Steroid Injection Triamcinolone acetonide injection beneath Tenon’s capsule (severe chronic anterior uveitis) Methylprednisolone acetate, triamcinolone acetonide (chalazion) Diane T. Adamczyk, OD Copyright © 2024 23 23 Anti-Inflammatory Drugs: Steroids PharmII Local Steroid Injection Advantage ◦ Place where needed ◦ Tx 1 eye/ uniocular tx ◦ Avoid most systemic side effects ◦ Noncompliant patient ◦ Role in surgery Diane T. Adamczyk, OD Copyright © 2024 24 Advantages of local steroid injection is when one eye is treated Good for non compliant pts who are not taking the topical you give them 24 Anti-Inflammatory Drugs: Steroids PharmII Local Steroid Injection Disadvantage ◦ Discomfort ◦ Subconjunctival adhesions ◦ Allergy to diluent ◦ Orbital infection ◦ Conjunctival ulceration ◦ Papilledema ◦ Potential Adrenal suppression Diane T. Adamczyk, OD Copyright © 2024 25 It can be uncomfortable and pt may have an allergic rxn to the vehicle the injection comes in 25 Anti-Inflammatory Drugs: Steroids PharmII Local Steroid Injection Adverse Reactions: ◦ Uncomfortable ◦ ^IOP ◦ RD, optic nerve atrophy Diane T. Adamczyk, OD Copyright © 2024 26 Uncomfortable means leads to increase in IOP 26 Anti-Inflammatory Drugs: Steroids PharmII Intravitreal Steroid Retise rt First intravitreal drug implant Treatment of chronic posterior segment uveitis Designed to deliver sustained levels of drug For a period of 30 months (many years) ADR: Increased IOP Cataracts Diane T. Adamczyk, OD Copyright © 2024 27 This was used for posterior segment uveitis 27 Anti-Inflammatory Drugs: Steroids PharmII Ophthalmic Drug Delivery Iluvien ◦ ◦ ◦ ◦ Cylindrical polyimide tube Release fluocinolone acetonide (FA) Intravitreal injection Non-erodible, intravitreal implant = so will ventually settle to the bottom of the eye ◦ Use: treatment of Diabetic Macular Edema (DME) ◦ Release FA: up to three years Diane T. Adamczyk, OD Copyright © 2024 28 Illuvien is a cylindrical tube and contains fluocinolone acetonide and it basically can be very easily injected into the eye It is one injection so that is convenient 28 Anti-Inflammatory Drugs: Steroids PharmII Steroid Intracanalicular Inserts Dextenza (dexamethasone ophthalmic insert) 0.4mg ◦ 30 days Diane T. Adamczyk, OD Copyright © 2024 29 This is put into the punctal pug and it slowly dissolves over the course of the month and slowly releases dexamethasone The various ways you can administer the steroid 29 Anti-Inflammatory Drugs: Steroids PharmII Systemic Steroid Treatment Indications: ◦ Posterior segment, ◦ optic nerve, ◦ orbit inflammation Commonly used drugs include: ◦ Prednisone (oral), ◦ methyl-prednisolone sodium succinate (inject/IV) Diane T. Adamczyk, OD Copyright © 2024 30 Prednisone is a common steroid used IV is another one 30 Anti-Inflammatory Drugs: Steroids PharmII Topical vs Periocular vs Systemic Topical Periocular Advantages Tx unioc Local Tx unioc Local Avoid most systemic effects Disadvantages Potential adrenal suppression Aggravate dendritic ulcer Diane T. Adamczyk, OD Copyright © 2024 Systemic Reach all parts of the eye Avoid most systemic effects Potential adrenal suppression Injection discomfort Adrenal suppression Systemic side effects Table m odified: 12-4, p269 B& J 31 Systemic if you want to reach all the structures of the eye You avoid the most systemic effects if you do topical Depending on how you administer it you have the potential for adrenal suppression and you do risk it with systemic steroids 31 Anti-Inflammatory Drugs: Steroids PharmII Steroid: Treatment Considerations Diane T. Adamczyk, OD Copyright © 2024 32 32 Anti-Inflammatory Drugs: Steroids PharmII Dosage Considerations Choice/dosage: dependent on location and severity of inflammation ◦ Severe eg. Q2H Dosage: should be high enough to suppress inflammatory response ◦ Determined by clinical experience, re-evaluation of treatment ◦ Minimal effective dose for shortest time for desired response Pulse therapy Diane T. Adamczyk, OD Copyright © 2024 33 Some considerations to think about: Trial and error come in effect with this one of the things looked at are which drug is used and how you administer and the severity Anterior seg cells and flare and depending on the drug it impacts treatment Prednisolone acetate is often used but using once a day isn’t enough but rather every 2 or 3 hours When treating with a steroid and controlling inflammatory response then say in comparison to an antibiotic, there is a half life so you give it based on that but with steroids it depends on the inflammatory severity the drug frequency à this is determined by trial and error A pt may have idiopathic iritis and may give her a topical steroid but when the steroid is tapered the iritis comes back but it is trial and error that determines the dosing à a slow taper may have been better here 33 Anti-Inflammatory Drugs: Steroids PharmII Pulse Therapy vs Loading Dose Pulse therapy: means the administration of suprapharmacologic doses of drugs in an intermittent manner to enhance the therapeutic effect and reduce the side effects. Loading Dose: Is 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 Diane T. Adamczyk, OD Copyright © 2024 34 With pulse therapy you give a high dose and it all goes away then you give another high dose à happening in pulses Loading dose if you starting off with a high dose and then you start to decrease it Typically pulse therapy isn’t used frequently but it can be used It doesn’t just to steroid but also anti infections 34 Anti-Inflammatory Drugs: Steroids PharmII Adamczyk’s Rule of Steroid Treatment Don’t be a …… Diane T. Adamczyk, OD Copyright © 2024 35 You have to squash it with a steroid so you cant just give a bit of the steroid you got to give a bunch and squash the inflammation Don’t be afraid of using it, use it judiciously If you don’t knock it out it will just continue to linger 35 Anti-Inflammatory Drugs: Steroids PharmII Principles of Steroid Treatment Long term, high dose therapy should not be D/Ced abruptly Taper (if on steroid longer than 1 week) ◦ Relapse: proliferating white cells, over-producing antibodies react with residual antigen, florid PMN chemotaxis and reaction ◦ May be days to weeks Short term, low dose topical treatment usually does not produce significant side effects Diane T. Adamczyk, OD Copyright © 2024 36 Immune system gets suppressed so if you stop it and if you are on steroid for a long time then the inflammation can come back so long term high dose therapy cant be stopped abruptly but should be tapered If someone is on a steroid for a longer then a week then you should taper it and if not as long as a week then may not have to taper it If you don’t taper it then all these cells come in b/c suppressed for so long so now want to rush in Sometimes tapering may take days to weeks and sometimes will take weeks to months QUIZ #3 UP TO HERE à may include tetracyclines if for resistance, so any studies at the end then can be asked in a question 36