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Pain and Inflammation
Terms in this set (69)
For pain, use _______. For inflammation use ________
topical NSAIDs or oral analgesics
ophthalmic steroids or oral steroids
Two mediators of inflammation that are made from the breakdown of AA are:
prostanoids/ thromboxanes and leukotrienes
What are the two most important prostaglandins that cause redness, swelling and pain?
PGE2 and PGI2
3 classes of analgesics
NSAIDs site of action is _____________
They decreases sensitivity of nociceptors
non specific inhibition of COX reducing prostanoid production.
They block all the cox
T or F A lower dose of NSAID is required to relieve pain compared to that needed to suppress inflammation
Which analgesic has no ceiling effect?
Does acetaminophen act peripherally or centrally?
blocks transmission of pain signal
Do opioids act peripherally or centrally?
block perception of pain
for mild to moderate pain and inflammation, the best choice is
For severe inflammation, need ____
Indications for NSAIDs
Chronic allergic conjunctivitis
miosis inhibition during surgery
Chronic/ poorly controlled uveitis to reduce steroid dosing
3 Topical NSAIDs we use
Voltaren (diclofenac) qid
Acular LS (ketorolac tromethamine) qid
Nevanac (nepafenac) tid
Benefits of Nevenac
Superoir PK (penetration)
increased effectiveness in posterior seg
clinical role in conditions caused by PG mediated vascular leakage eg CME
Newest NSAIDs (not available in Can)
Xibrom (bromfenac) bid
Bromday (bromfenac) qd
The only NSAID available in single use vial.
Acuvail (ketorolac) qid
For pain and inflammation after cataract surgery
Ocular ADRs of NSAIDs
light sensitivity, bad taste, feeling of pressure
prolonged use can mask infection
appearance of sterile peripheral infiltrates because leukotriene pathway unopposed
Can progress to corneal melt
Warnings with topical NSAIDs
cross reactivity with other NSIADs
potential for increased bleeding due to platelet aggregation inhibition
Precautions with NSAIDS
individuals using other meds that increase bleeding
may delay healing
epithelial breakdown, corneal erosion, thinning, ulcers, perforation
used for ocular pain
OTC or prescription
Contraindications to oral NSAIDs
serious kidney or liver problems
Which patients should not use acetaminophen?
Ocular ADRs with oral NSAIDs
colour vision defects
Is acetaminophen an anti inflammatory?
Indications for acetaminophen
oral analgesic only
Rx non narcotic oral analgesic
tramadol HCl (US only)
acute pain relief
Narcotic analgesics are reserved for
Are opioids anti inflammatory?
Opioids are combined with _____
eg. codeine (tylenol 3)
oxycodone (tylox, percocet)
Recommmened non narcotic analgesics for optometric use
ibuprofen (motrin, advil, nuprin)
acetaminophen (325- 650 mg q 4-6h) not exceeding 4 g per day
T or F: Steroid s block all the inflammatory mediators
greater anti-inflammatory effects than NSAIDs
Should steroids be used long term?
Situations to NOT use steroids
acute bacterial or fungal infection
significant corneal epithelial defect
diagnosis is uncertain
Strongest anti inflammatory steroid form?
Acetate because most lipophilic- increased corneal penetration
alcohol less potent, phosphate even less
Ocular ADRs of glucocorticoids
Increase in IOP/ steroid induced glaucoma
delayed corneal epithelial healing
posterior subcapsular cataract
Armaly criterion for IOP increase in steroid use
Low= <6 mmHG
In an infectious scenario, always use a:
steroid/ antibiotic or steroid/ antiviral combination
Why should we taper steroids?
To avoid rebound inflammation
glucocorticoids reduce leukocytes, can be produced in massive amounts when tx stopped= inflammatory rxn
In general steroid dosing for:
mild/ moderate: q4h/ q6h
Severe: q1h or q1/2h
Pulse dosing needed to get control of severe inflammation
Would mild uveitis or sever dry eye require more frequent dosing?
What is essential to do when tx with steroids?
Frequent follow ups
Look at effectiveness and ADRs
For moderate to severe inflammation
prednisolone acetate (pred forte)
dexamethasone alcohol (maxidex)
For mild inflammation
fluorometholones (flarex, eflone, FML)
Why is brand pred forte better than generic?
Particles smaller and more uniform
Do you have to shake Pred forte?
its a suspension
What is the cheaper option of pred forte that is the same exact thing?
ratio prednisolone acetate (allergan)
Which steroid has greatest potential for IOP increase?
(dexamethasone alcohol= Maxidex)
fluorometholone is good for ____ inflammation and ________ admin
acetate suspension= flarex, eflone
alcohol suspension= FML
less likely to elevate IOP
What are the benefits of ester steroids
inactivated by naturally occurring esterases
no rebound effect
Ketone steroids are more risky because
stay in AC post breakdown as active metabolites
What are soft steroids?
inactivation occurs in single step, no intermediates to create ADRs
True Soft Steroid
Loteprednol (lotemax 0.5%, alrex 0.2%)
Do not need to taper
less rise in IOP
Semi soft steroid
Lotemax has steroid class labelling which means...
indicated for inflammation, acute anterior uveitis, GPC, seasonal allergic conjunctivitis, everything!
T or F: lotemax has equal efficacy to pred forte
Benefits of Lotemax Gel
less BAK than suspension
pH 6.5, close to tears
BAK free steroid options
Durezol (preserved with sorbic acid)
prednisolone phosphate in single use
Do you have to shake Durezol?
NO its an emulsion
Can we prescribe oral steroids?
Indications for oral or injectable steroids
uveitis not responding
posterior uveitis or chorioretinitis
Most common oral steroid
mild to moderate: 20-40 mg qd
more severe: 60-80 mg split bid
Oral steroid 6 day taper pack
Medrol dosepak (methylprednisolone)
Can oral steroids be used as pulse therapy without tapering?
eg. severe lid swelling: 60 mg first day, 40 mg second, discontinue
When to use steroid/ antibiotic
inflammation conditions of ant seg where there is risk of infection
Main purpose of an antibiotic/ steroid?
the two most important antibiotic/ steroid combos
tobradex (dex 0.1, tobramycin 0.3)
zylet (lotoprednol 0.5, tobramycin 0.3)
What's maxitrol contain?
Tx for contact dermatitis around eyes
steroids for limited time
protopic (tacrolimus 0.03%, o.1%): do not use long term or in kids under 2
Cyclosporin A (Restasis)
Tx for inflammatory surface disease
Cannot rx in ontario
THIS SET IS OFTEN IN FOLDERS WITH...
Anti Infectives Intro
Pharmacology - Diabetic Agents
Pharm- Pain Mgmt
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