drugs used in uveitis capt ferdous
TRANSCRIPT
![Page 1: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/1.jpg)
Drugs used in Uveitis Capt Md Ferdous Islam
Trainee in OphthalmologyCMH ,Dhaka
![Page 2: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/2.jpg)
Introduction
• The purpose is to describe the different drugs used in the treatment of uveitis. The term drug would incl eye drops, tablets and injections.
• It may be useful to remember the aims of treatment in uveitis:
![Page 3: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/3.jpg)
What Should Treatment Achieve?• Relieve pain and discomfort.• Prevent sight loss due to the disease or its
complications.• Treat the cause of the disease where possible,
that is, treat the inflammation.• In a few types , the inflammation is caused by
an infection and treated with antibiotics or antiviral drugs.
• The drugs fall into 3 main groups: Steroids, Immunosuppressants and Mydriatics
![Page 4: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/4.jpg)
Cycloplegics Mydriatics
• These ophthalmic preparations block the responses of the iris sphincter and the accommodative muscle of the ciliary body to cholinergic stimulation, producing pupillary dilation (mydriasis) and paralysis of accommodation (cycloplegia)
• Tropicamide 1%, cyclopentolate and atropine have both properties
• Phenylephrine has only mydriasis.
![Page 5: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/5.jpg)
CycloplegicsPurpose:•To break or prevent posterior synechiae and to relieve ciliary spasm induced photophobia.•Dosing depends on the extent of inflammation
![Page 6: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/6.jpg)
Posterior synechiae
![Page 7: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/7.jpg)
CorticosteroidsMainstay of initial therapy
![Page 8: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/8.jpg)
![Page 9: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/9.jpg)
Topical Steroids
Cunningham, Emmett. Practical approach to the use of corticosteroids in patients with uveitis. Can J Opthalmol 2010; 45:352-8
![Page 10: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/10.jpg)
Topical Steroids
![Page 11: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/11.jpg)
Injections
![Page 12: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/12.jpg)
Adverse Effects of Corticosteroids
![Page 13: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/13.jpg)
Cont.
![Page 14: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/14.jpg)
Cont.
![Page 15: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/15.jpg)
NSAIDS
![Page 16: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/16.jpg)
Systemic NSAIDSComplications of prolonged use:• Myocardial infarction• Hypertension• Stroke (selective cox-2 inhibitors) • PUD• GI bleeding• Nephrotoxicity• Hepatotoxicity
![Page 17: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/17.jpg)
Immunomodulatory Medications (IMT)
• Antimetabolites• T Cell Signaling Inhibitors• Alkylating Agents• Biologic Response Modifiers
![Page 18: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/18.jpg)
![Page 19: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/19.jpg)
![Page 20: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/20.jpg)
Indications For IMTInadequate response of uveitis to corticosteroid therapy for
greater than 3 months with doses exceeding 5-10mg/day.Vision threatening Intraocular inflammation.Reversibility of disease process.Contraindications to corticosteroid use: 1. diabetes, hypertension, peptic ulcer, GERD,
immunocompromised state, psychiatric conditions2. exacerbated side effects3. chronic corticosteroid dependence
![Page 21: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/21.jpg)
Precautions
No infection presentNo hepatic or hematologic contraindicationsClose physician follow upTeratogenicInformed Consent
![Page 22: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/22.jpg)
Antimetabolites• Azathioprine, methotrexate, mycophenolate mofetil• Azathioprine (purine nucleoside analogue)-interferes with DNA replication and RNA transcription-found beneficial in VKHsyndrome, int. uveitis, Behcet uveitis,
sympathetic opthalmia and necrotizing scleritis-GI side effects (nausea, upset stomach) are cause for D/C.-CBC, LFT every 4-6 weeks.
![Page 23: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/23.jpg)
Methotrexate• Folic Acid analogue• Inhibitor of dihydrofolate reductase and it’s DNA replication• Causes extracellular accumulation of adenosine to create an
anti-inflammatory effect.• Useful for iridocyclitis (first line choice IMT treatment for
children), sarcoidosis, panuveitis, various other types of uveitis
• Prospective study for IV inj. for refractory uveitis and uveitic CME.
![Page 24: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/24.jpg)
Mycophenolate Mofetil
• Inhibits inosine monophosphate dehydrogenase and DNA replication
• Side effects: reversible GI distress, diarrhea• CBC monthly• 85% effectivity in chronic uveitis patients and a good
second choice IMT for children.
![Page 25: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/25.jpg)
CYCLOSPORINE and TACROLIMUS• Calcineurin inhibitors- disrupt T-cell
receptor signal transduction and down regulate IL-2 transcription and CD4 T lymphocyte receptor expression.
SIROLIMUS• Non-calcineurin inhibitor- disrupts T cell
signaling that inhibits Ab production and B-lymphocytes.
T Cell Signaling Inhibitors
![Page 26: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/26.jpg)
Cyclosporine
• SE: Nephrotoxicity and systemic hypertension; paresthesia, hypertrichosis.
• BP, CBC, s creatinine monthly.• Used for int. uveitis and posterior uveitis cases from
Behcets and VKH.• Used in combination with corticosteroids
![Page 27: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/27.jpg)
Tacrolimus
• Low dose and increased potency to cyclosporine• Less risk of hypertension and hyperlipidemia• Useful for chronic int. and posterior uveitis.• Nephrotoxicity
![Page 28: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/28.jpg)
Sirolimus
• One open-label, prospective study it was found useful in treatment for refractory noninfectious uveitis
• GI side effects• Under active investigation for use in treating uveitis
![Page 29: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/29.jpg)
Alkylating AgentsCYCLOPHOSPHAMIDE• Active metabolites alkylate purines in DNA and RNA, creating
impaired DNA replication and cell death• Cytotoxic to dividing and resting lymphocytes• myelosuppression, hemorrhagic cystitis, sterilityCHLORAMBUCIL• Interferes with DNA replication• myelosuppression, sterilityTreatment for int. uveitis, VKH, SO, Behcet Increased risk for malignancy (leukemia, various cancers)
![Page 30: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/30.jpg)
Biologic Response Modifiers{inhibitors of cytokines}
INFLIXIMAB• Chimeric, monoclonal IgG1k antibody against TNF alpha• Treatment for Behcet, sarcoidosis and VKH. Some HLA B27
ant. Uveitis • Drug induced toxicity (lupus, systemic vascular thrombosis,
CHF, malignancy, demyelinating disease and vitreous hemorrhage)
ADALIMUMAB• less AE, same effectiveness
![Page 31: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/31.jpg)
Alternative Therapy Under FDA Investigation
• RITUXIMAB chimeric monoclonal antibody against CD20 positive cells (B lymphocytes)
• DACLIZUMAB monoclonal Ab to IL-2• IFN alpha 2a: antiviral, immunomodulatory and
antiangiogenic effects (leukopenia and thrombocytopenia,depression)
![Page 32: Drugs used in uveitis capt ferdous](https://reader034.vdocument.in/reader034/viewer/2022042515/587aa8da1a28abed218b4f97/html5/thumbnails/32.jpg)