Ocular anti-inflammatory drugs: corticosteroids

whats the endogenous glucocorticosteroid

cortisol

cardinal inflammatory responses

1. rubor - increased permeability - fluid release into tissues

2. dolor - systemic response

3. tumor - increased permeability

4. calor - capillary widening - increased blood flow

glucocorticosteroids effect on body

1. innate immunity

2. adaptive immunity

3. anti tumor immunity

can NSAID impact all 4 cardinal signs?

no

glucocorticosteroids can tho

HPA axis

1. hypothalamus

   1. corticotropin releasing factor (CRF) —> stimulates anterior pituitary to secrete adrenocorticotropin (ACTH)

2. anterior pituitary

   1. secretes ACTH

      1. gives:

         1. glucocorticoids = anti inflammatory and immunosuppression

         2. mineralocorticoids = salt and water retaining

            1. INCREASES BP, sometimes IOP

         3. sex hormones

3. aldosterone secretion (not asking ? specifically on )

   1. regulated by angiotensin

      1. renin in plasma released by kidney in response to blood sodium levels

zona fasciculata

1. where endogenous glucocorticoids are released

2. in cortex of adrenal gland

3. regulated by AC

zona reticularis

adrenal androgens

zona glomerulosa

mineral corticoids

medulla of adrenal gland

catecholamines

what do glucocorticosteroids inhibit

phospholipase A2

anti inflammatory effects of glucocorticosteroids

1. inflammatory responses decreased

   1. cardinal symptoms dec

2. inhibition of phospholipase A2

   1. lymphocytopenia induced

      1. decreases WBC - immunosuppression

   2. inh of chemotaxis

   3. prostaglandin synthesis inh

      1. NSAID work here too

3. suppression of

   1. edema

   2. capillary dilation

   3. scar formation

   4. wound healing

      1. could make an infection worse in the eye

4. manifestations are supressed

5. UNDERLYING CAUSE REMAINS

ophthalmic steroids drugs

1. prednisolone

2. difluprednate

3. dexamethasone

4. fluorometholone (FML)

5. loteprednol

6. rimexolone

soft steroids

soft steroids

good anti inflammatory actions w less impact on IOP

side effects less intense

what are the soft steroids

1. loteprednol

2. fluorometholone

3. rimexolone

ocular side effects of steroids

1. posterior subcapsular cataract

   1. no sig reduce in VA

   2. after long term topical/systemic use

2. glaucoma

   1. LESS LIKELY W LOTEPREDNOL, RIMEXOLONE, FML

   2. IOP elevation is reversible after discontinuation

3. secondary infections

   1. bacterial, viral, fungal

4. retardation of corneal ep healing

   1. INH OF WOUND HEALING

is high dose short period of time or low dose long period of tie worse

low dose long period of time

what does the steroid respone impact

outflow of aq humor

mech of posterior subcapsular cataract

1. changes w lens fibers and proteins

2. Corresponds with duration of treatment

3. More likely with oral steroids; less likely with Lotemax (ester)

ocular physiologic effects of retina

1. dec retinal oxygen consumption

2. increase glycogen content

3. vasoconstriction/ dec in capillary pressure near fovea

4. CSCR/ICSC (idiopathic CSC)

   1. central serous chorioretinopathy

   2. serous blood vessels leaks out of BV

   3. SYMPATHOMIMETICS CAN ALSO CAUSE THIS

      1. body secretes more cortisol when scared

anterior segment side effects

 Delayed wound healing (epithelium)

Risk of infection

 Glaucoma (Ocular hypertension aka IOP spike)

 Posterior subcapsular cataract

posterior segment side effects

 CSCR (central serous chorioretinopathy)

are corticosteroid side effects dose dependent

YES

after how many days must you taper a systemic steroid

high dose

and/or greater than 14 days of treatment

systemic side effects of steroids (9)

1. adrenal insufficiency

   1. less likely w drops

2. cushings syndrome

   1. most often w long term steroids

   2. muscle atrophy

   3. redistribution of body fat

   4. purple stretch marks

3. peptic ulceration

   1. TAKE THESE W FOOD

   2. TAKE NSAIDS W FOOD TOO

4. osteoporosis

5. hypertension

   1. most systemic steroids have low salt adn water retention but its not 0

6. inh of growth

   1. skeletal maturation

   2. children

7. diabetes

   1. these will put someone close to diabetes into diabetes

8. activation of infection

   1. supression of immuen response

9. delayed wound healing

glucocorticoids phys effect

1. carbohydrate/protein metabolism

   1. inc glucose production

      1. inc blood sugar level

      2. DM pt

   2. liber glycogen storage inc

2. lipid metabolism

   1. redistribution of body fat

      1. back of neck hump

      2. moon face

      3. lost from extremities

3. CNS

   1. mood changes