Oc Pharm 2 (Corticosteroids)

What does functio laesa meaning?

loss of function

What are the 4 inflammatory responses?

rubor, dolor, tumor, calor

What makes up the HPA axis?

hypothalamus, pituitary gland, adrenal gland

What stimulates the anterior pituitary to secrete ACTH?

CRF (corticotropin releasing factor) made by the hypothalamus

What system is aldosterone secretion a part of?

renin-angiotensin (RAS system)

When should steroids be tapered?

if used for more than 14 days and/or if used at high dose

Why do ocular steroids cause an increase in IOP?

they have fluid shifting properties and outflow facility is reduced

Where are mineralocorticoids produced?

zona glomerulosa of the adrenal cortex

Where are glucocorticoids produced?

zona fasciculata of the adrenal cortex

Where are adrenal androgens produced?

zona reticularis of the adrenal cortex

Where are catecholamines produced?

adrenal medulla

What hormone is produced when angiotensin II stimulates the zona glomerulosa?

aldosterone

What hormone is produced when ACTH stimulates the zona fasiculata and zona reticularis?

cortisol and adrenal androgens

What hormone is produced when sympathetic nervous system stimulates the adrenal medulla?

epinephrine and norepinephrine

What is the MOA of steroids?

inhibits phospholipase A2

What does the the inhibition of phospholipase A2 lead to?

lymphocytopenia (decrease in WBCs), inhibition of chemotaxis and inhibition of prostaglandin formation

Do steroids treat the underlying disease?

no the underlying cause remains

What are the topical ophthalmic steroids currently available?

prednisolone, difluprednate, dexamethasone, fluorometholone (FML), loteprednol, rimexolone

Which topical ophthalmic steroids are considered "soft-steroids"?

fluorometholone (FML), loteprednol, rimexolone

Which topical ophthalmic steroids is most likely to cause an increase in IOP?

Durezol (difluprednate)

Where do infiltrates enter the anterior chamber from in scleritis?

major and minor circle of the iris

What must be used in conjunction to durezol in the treatment of scleritis to combat more infiltrates from entering the anterior chamber?

cyclopentolate

Do ointments contain preservatives?

No

What is Zylet comprised of?

loteprednol etabonate 0.5% and tobramycin 0.3%

What is Maxitrol comprised of?

neomycin, polymyxin B sulfates, and dexamethasone

What is a side effect of Maxitrol?

red, itchy eye due to neomycin (possible allergic rxn)

Which ophthalmic steroid is used in Lotemax?

loteprednol etabonate

What type of technology does Lotemax SM use?

submicron

Which ophthalmic steroid is used in Inveltys?

loteprednol etabonate

What type of technology does Inveltys use?

micro-particle

Which ophthalmic steroid is used in Pred Forte and Pred Mild?

prednisolone acetate

Which ophthalmic steroid is used in Maxidex?

dexamethasone

Which ophthalmic steroid is used in Vexol?

rimexolone

Which ophthalmic steroid is used in Alrex?

loteprednol etabonate

Which ophthalmic steroid is used in Flarex?

fluorometholone acetate

What are indications for ophthalmic steroid use?

blepharitis, keratoconjunctivitis sicca, conjunctivitis, herpetic keratitis, infiltrative keratitis, uveitis, episcleritis, pterygium, post op ocular sx

What are ocular side effects of ophthalmic steroid use?

PSC, glaucoma, secondary infections, retardation of corneal epithelial healing

Which ophthalmic steroids are less likely to cause glaucoma?

loteprednol, rimexolone, FML

How do steroids effect aqueous outflow?

inhibit degradation of ECM material and causes phagocytosis in Schlemm's canal

When does an IOP increase secondary to steroids occur?

~2 weeks after initiation

Which steroids are more likely to cause the formation of a posterior subcapsular cataract?

oral steroids

What retinal condition is associated with the use of steroids?

central serous chorioretinopathy (CSCR/ICSC)

What is CSCR usually caused by?

excess epinephrine exacerbated by steroid use

What are physiologic effects of steroid use on the retina?

decreased retinal oxygen consumption, increase glycogen content, vasoconstriction/decreased capillary pressure near fovea

What is found as flare in the anterior chamber?

albumin

What is albumin produced by?

liver

Why may flare occur in a patient using a steroid?

it decreases the ability of albumin to resist the hydrostatic forces induced by blood

True or False. Short term, high dose therapy leads to less side effects than prolonged low dose steroid use.

True

What is expected in a patient with an increased IOP secondary to steroid use after the discontinuation of the steroid?

IOP returns to normal

What are systemic side effects of steroid use?

adrenal insufficiency, Cushing's syndrome, peptic ulceration, osteoporosis, HTN, DM, inhibition of growth, activation of infection, delayed wound healing

What does low cortisol and aldosterone cause?

Addison's disease

What does excess cortisol lead to?

Cushing's syndrome

What is expected in a patient with an diabetes secondary to steroid use after the discontinuation of the steroid?

blood glucose returns to what it was but health risks remain the same as a diabetic

Why can steroid use cause a pre-diabetic patient to become diabetic?

increased blood sugar level and liver glycogen storage

Which ophthalmic steroid base is needed for deeper drug penetration?

acetate

If inflammation is past the pars plana will a topical steroid work?

No

Which ophthalmic steroid base is most lipophilic?

acetate

What form of topical steroid is best for internal eye inflammation?

suspensions

What form of topical steroid is best for external eye inflammation?

solutions

Which ophthalmic steroid is the gold standard?

Pred Forte/Ominpred (Prednisolone acetate 1%)

How does the dosing of Durezol (Difluprednate) differ from Pred-Forte?

dosed 1/2 of Pred-Forte regimen

What is the strongest ophthalmic steroid?

Durezol

What is the difference between Tobradex and and Tobradex ST?

Tobradex ST contains xanthan gum to allow the drug to stay in the system for longer

What does "ST" stand for?

sustained therapy

Why does fluorometholone (FML/FML Forte) have poor corneal penetration ultimately decreasing its efficacy compared to Pred-Forte?

alcohol suspension

What makes Flarex a more effective medication than FML and FML Forte?

it is an acetate suspension

Why is loteprednol less likely to cause an IOP spike?

ester-base medication

What feature of loteprednol contributes to its improved safety profile?

it is metabolized into inactive form once the target tissue is reached

What is Inveltys mainly used for?

post-op cataract sx

What is recommended when prescribing Xiidra or Restasis to combat dry eye?

prescribe ophthalmic steroid in conjunction for first 4 weeks

Which ophthalmic steroid is approved specifically for short term dry eye therapy?

Eysuvis

How does the efficacy of Vexol 1% compare to Pred-Forte 1%?

equally as effective

What is the benefit of using Vexol over Pred-Forte?

lower tendency to raise IOP

Do you need to taper a combination antibiotic/steroid?

No, but better safer than srry ;)

Why should steroids be tapered?

to avoid rebound inflammation

What topical steroid is most commonly used in the treatment of periorbital contact dermatitis?

hydrocortisone 0.5% / 1%

What are side effects of hydrocortisone 0.5% / 1%?

skin atrophy, dryness, hypopigmentation, secondary infection

What are intravitreal steroids used for?

macular edema, DM retinopathy, vein occlusion, Irvine Gass Syndrome, proliferative vitreoretinopathy

What are benefits of intravitreal steroid injections?

better compliance, bypasses BAB/BRB, reduced systemic toxicity

What intravitreal steroids are currently available?

Retisert, Iluvien, Ozurdex

How long does Retisert last?

2.5 years (has to be removed)

How long does Iluvien last?

3 years

How long does Ozurdex last?

6 months

What is the max adult dose of oral prednisone?

60-80 mg/day

When are IV steroids indicated?

optic neuritis, severe corneal graft rejection, sight threatening posterior uveitis, sympathetic ophthalmia, VKH