Pharmacological Treatment in DED Flashcards
1
Q
Describe level 2: topical anti-inflammatories (DED)?
A
- Steroids – designed to bring down inflammation, short-term use – not initially – tried intensive compliant lid hygiene & lubrication & getting no relief & seeing signs of inflammation (conj hyperaemia)
- Cyclosporin
- Designed for short term use where there is a severe inflammatory reaction i.e. intense conj hyperaemia
o Could be used when someone who is compliant gets a bad flare up – which could be triggered by risk factors or where they present to you as a very severe px
2
Q
Describe steroids use in DED?
A
- Loteprednol (Lotemax) – non-penetrating
- Dexamethasone (Maxidex/Dropodex)
- Prednisolone (Predsol/Pred Forte) – Predsol is non-penetrating (weaker conc)
- Fluoromethalone (FML) – non-penetrating
o Want it non-penetrating as not dealing with anterior uveitis, only cornea or further forward – don’t want it to penetrate further in anterior chamber or uvea - Dosage e.g.:
o FML – QID for 1 week (can choose to taper over next 3 weeks – TID for 1wk, BDS for 1wk, OD for 1wk)
But could stop after 1 week
o Loteprednol – QID for 1 week (can choose to taper over next 3 weeks)
o CMG says: “may be considered for short-term use in some cases”
o Some ophthalmologists use penetrating steroids e.g. Pred-Forte or Dropodex - Contraindications/Cautions:
o Infection, be confident in diagnosis – steroids are immunosuppressant
o Glaucoma – steroids can cause glaucoma – non-penetrating less likely to raise IOPs but risk is there
o CLs
o Pregnancy & breast-feeding - Side-effects (more than just following):
o Raised IOP
IOP should be monitored, even on non-penetrating steroids. Make sure to check this at the dry-eye follow up
o PSCC formation
o Secondary infection – reduces immune system
o Headache - BRING THESE PXS BACK AFTER A WK – CHECK IOPs AT THIS POINT – should see reduction in inflammation
- Steroids should be used in short bursts – not long term
Need to include no. of drops, BEs, how many times a day
Be clear on conc of drug and full name (not abbreviation)
3
Q
Describe cyclosporin/ciclosporin as treatment in DED?
A
- Immunomodulatory drug (not a steroid) w/ anti-inflammatory properties
- Strong level 1 evidence to support the use of cyclosporin
- Initiated by ophthalmologist
o They may request an IP optometrist to issue an Rx - Expensive - £72 for 30 single does units (2017 price)
- UK name is Ikervis (aka Restasis in America) concentration is 0.1%
- For use once a day – can sting on instillation (advise px)
- Some ophthalmologists use this as a trial to see if it is inflammatory – so if sxs improve then they know its inflammatory – if doesn’t improve something else going on
- Contraindications/Cautions:
o Hypersensitivity to the agent
o Active or suspected ocular infection – as still having effect on immune system
o Ocular or peri-ocular malignancies
o Pregnancy/breast feeding
o No trials have been done in children
o Glaucoma – cautioned because don’t know what it does in glauc – not enough research yet
o Ocular herpes – don’t know its affect
o Contact lenses
4
Q
Describe level 2: topical antibiotics in treatment for DED?
A
- Tends to be used short term to reduce bacterial load in blepharitis
- Can be used pre-surgery – especially cataract surgery
o Pxs referred for cat. surgery with severe bleph may be a reason for the surgery not to go ahead
o So start pxs on bleph regime if they are being referred to prevent them being bounced back - Options listed in CMG for bleph are chloramphenicol & azithromycin
- Chloramphenicol:
o 1% eye ointment
o Rubbed into the lid margin w/ a clean fingertip BD for 1 week
o Px must then continue with lid hygiene – not instead of
o Entry level, available to all optoms – don’t go for this as default option but if severe bleph consider
o Off label use but recommended in guidelines
o Must not be used in pregnancy or breastfeeding - Azithromycin:
o Azyter: eye drops, 1.5% azithromycin dehydrate
Preservative free, individual vials
o OFF LABEL USE – good option for bleph but not listed as one of the drugs uses
Must write this on record card and ask px if they are okay with that
o Also has mild anti-inflammatory properties
o Research has shown improvement in signs & sxs & greater efficacy than hot compresses alone
o BD for 3 days (same as for bacterial conjunctivitis) – shorter does than chloramphenicol
o IP Qualification required
o Can be used in pregnancy and breast feeding - Fusidic Acid:
o Unlike chloramphenicol fusidic acid can be used in pregnancy and breast feeding
o Entry level
o Off label use – its licensed for bacterial conjunctivitis rather than bleph
o £32.29 for 5g (Chloramphenicol ointment is £1.74)
Not used as often now due to price
Use when px allergic to chloramphenicol or pregnant/breastfeeding
o Twice a day for a week - Be familiar with all 3 – look at BNF
5
Q
Describe level 2: systemic tetracycline in treatment for DED?
A
- Anti-infective - anti-biotic
- Also has anti-inflammatory effects
- Long standing blepharitis is characterised by inflammation of eyelids
o Telangiectasia, capped glands
o DO NOT go for these before lid hygiene, ocular lubricants - IP level intervention or GP may prescribe
- When?
o Considered as 2nd line management option according to CMG on bleph
o Recommended for posterior bleph
o For chronic cases
o Those that have not responded to standard management
o When there is associated rosacea (co-management w/ dermatologist or GP)
o Mixed literature on efficacy - Which one?
o Doxycycline
o Minocycline
o Tetracycline
o Oxytetracycline
Doxycycline & minocycline obtain a higher conc in tissue & longer half life
There are no randomised, double masked clinical trials that compare tetracyclines with other methods of lid hygiene
Research is a mix of case reports, unmasked trials or trials comparing tetracyclines to placebo – need large scale trials comparing tetracyclines to each other & lid hygiene - Dosage:
o Doxycycline – 100mg twice daily for 2 weeks then once daily for 2-3months. Or 40mg modified-release for at least 5 months
When it is for ocular rosacea then CMG recommends Doxycycline 40mg modified release once daily for up to 6wks
o Minocycline – one 50mg tablet for 2 weeks followed by 100mg daily for 10weeks
o Tetracycline – not listed on College Formulary
o Oxytetracycline – not listed on College Formulary - Contraindications:
o Hypersensitivity to drug
o Hypersensitivity to any members of tetracycline family
o <12 years of age
o Pregnancy or breast feeding – crosses placenta and expressed in breast milk
o Renal or hepatic impairment
o Systemic lupus erythematosus (SLE) - Cautions:
o Photosensitivity – they will burn more quickly so advise very strong suncream
o Caution when using oral contraceptives – may reduce effect, speak to GP
o Antacids 2 hours before or after taking tetracyclines – decrease absorption of tetracycline
o Use in Myasthenia Gravis/SLE
o Pxs taking anticoagulants, may require a dose reduction in tetracycline – need to speak to GP - Side Effects:
o Can include blurred vision, field loss, diplopia, discoloration of conj & lacrimal secretions – there are rare, but presence can indicate Benign Intracranial Hypertension
o GI disturbances – common
o Hypersensitivity
o Headache – can indicate BIH
o Photosensitivity – advise them not to use tanning beds, take care in sun - Advise to Px:
o Limit time in sun & use high factor suncream
o No tanning equipment
o Alternative forms of contraception should be used during tx
o To return if they experience any side effects – potential to be serious side effects
Let GP know about any prescription you give
6
Q
Describe oral azithromycin in treatment for DED?
A
- For those where tetracyclines are contraindicated then consider oral azithromycin
- May improve MGs function in unresponsive MGD – much shorter course tetracyclines
- IP OPTOMS ONLY
- 500mg on day one, 250mg for 4 days
- Caution in Myasthenia Gravis
- Caution in pregnancy & breast feeding
- Caution in hepatic & renal impairment
- There is a long list of potential side effects for all Macrolide antibiotics
- The only ‘common or very common’ one with oral azithromycin is arthralgia (joint stiffness)
7
Q
Describe co-management of DED?
A
- Who should you inform of your tx plan?
- Letter should be written to px’s GP informing them of any Rxs issued, this should be done promptly – within 48hours
- Fine to speak to GP before issuing prescription & ask for advice – to find out other drugs px is on
- Need pxs consent before you can phone GP and ask for that info
- Also make sure to be communicating w/ dermatology if applicable
8
Q
Describe level 2: topical secretagogues for DED?
A
- Secretagogues are agents that are designed to stimulate production of aqueous, lipid and/or mucin
- Topical diquafosal/tetrasodium (aqueous & mucin – currently not licensed in UK/EU)
- Topical Rebamipide ophthalmic suspension (mucin – currently not licensed in UK/EU)
- Topical testosterone (lipid – currently not licensed in UK/EU)
9
Q
Describe level 3: autologous serum for DED?
A
- Vials of autologous serum-based eye drops are made from a blood donation from px or from a donor
- Believed that autologous serum can better promote healing & growth of corneal epithelial cells
o For v severe pxs where level 1 & 2 haven’t worked - One full blood donation produces up to 150 vials diluted with 50% saline with a shelf life of 12mths from date of donation
- Expensive - £1,100 for 3-5mths’ supply (including delivery to px’s home address w/ same day courier)
- For ophthalmologist to prescribe this, need a lot of evidence that level 1 and 2 have not worked and that this is having a real impact on quality of life – not something that is rushed to
10
Q
Describe level 3: fingerpirick autologous blood in DED tx?
A
- Applying pin prick of blood onto conjunctiva 4x a day
- Barriers – time required for training, manual dexterity (rheumatoid arthritis etc), fear of needles, any infections
- Would be initiated by or w/ oversight & collaborations from ophthalmology
11
Q
Describe level 3: systemic secratagogues in DED tx?
A
- Oral pilocarpine (aqueous) – licensed in UK
o Been investigated & shown to improve signs & sxs of DED, but w/ associated side-effects of nausea & sweating – these side-effects for px can often outweigh the use
o Not widely used as limited research & few clinical trials carried out - Oral cevimeline (aqueous) – NOT licensed in UK/EU
12
Q
Describe level 4: amniotic membrane in DE tx?
A
- Promotes corneal healing in severe dry eye (as well as post-surgery or for chemical burns)
- Derived from inner layer of amniotic sac – made of an extracellular matrix which has anti-inflammatory, anti-bacterial & anti-scarring properties amongst others
- Similar to a large CL
- Length of time varies – depending on manufacturer using – often dissolves in place or is taken out after a length of time
13
Q
Describe neuropathic pain?
A
- Can present v like dry eye disease or alongside it
- Pain, irritation, discomfort – intense
- Can be post injury, post-surgery, post-laser pxs, diabetes, shingles
- Standard management options helpful as want to restore ocular health & ensure no further nerve damage/reduce inflammation as much as possible
- Pxs may benefit from co-management with GP or referral to pain management clinic as this may not be confined to eye
- May also need to target central issue w/ nerves & that can require systemic meds
- Co-management with GP:
o Tri-cyclic antidepressants e.g. amitriptyline
o Anti-epilepsy e.g. gabapentin
Work by trying to reduce nerve’s hypersensitivity in general, which stops over-sensitivity and pain
14
Q
When should you refer Dry Eye?
A
- Normally no referral
o If idiopathic & not associated w/ systemic disease - Routine referral if adequate trial of topical tx (this does not mean just first line drops) or punctal plugs fail
- Secondary complications (vascularisation, cornea scarring, melt, or infection) – depending on complication will determine the urgency
- If condition is not idiopathic, e.g. Sjogren’s syndrome or an unidentified underlying disease are suspected, refer (this may be to GP)
o If suspect px has Sjogren’s but dry eye is doing well and manageable in practice then could refer to GP for blood test - If lid anatomy or function is abnormal – routinely refer e.g. ectropion
- If SJS or OCP are suspected, refer urgently (within one week) to ophthalmologist
15
Q
When should you refer blepharitis?
A
- Alleviation/palliation: normally no referral
- In unilateral cases, if meibomian gland carcinoma is suspected, refer urgently (within one week)
o In normal bleph you will see signs in both eyes - In pxs who do not respond to therapy the possibility of carcinoma or immune mediated diseases should be considered, particularly if the bleph is associated w/ loss of eyelashes &/or cicatricial changes
