Medication Summary
The goal is to suppress intraocular inflammation, which usually is accomplished with systemic corticosteroids. In some cases, this treatment is inadequate, and immunosuppressive or immune-modulating agents are required to control the disease. These agents can be used adjunctively with steroids or alone.
Corticosteroids
Class Summary
Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
Prednisone (Deltasone, Meticorten, Orasone)
Readily absorbed through the GI tract and inhibits phospholipase A2 (an enzyme that liberates arachidonic acid from phospholipids in the production of inflammatory mediators).
Triamcinolone (Amcort)
A long-acting depo-steroid. For inflammatory dermatosis responsive to steroids; decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. Observe for ptosis or anterior dissection. Generic preparations appear to be equally efficacious compared to proprietary Kenalog.
Prednisolone 1% (Pred Forte)
Has 3-5 times the anti-inflammatory action as hydrocortisone. Glucocorticoids inhibit the edema, fibrin deposition, capillary dilation and phagocytic migration of the acute inflammatory response. Steroids are also potent inhibitors of the inflammatory enzyme cascade, angiogenesis, and mast-cell degranulation. Steroids stabilize cell membranes.
Loteprednol etabonate binds to anti-inflammatory receptors 4.3 times more avidly than dexamethasone. Possible reduced risk of glaucoma due to ester substitution for ketone moiety at the 20 position on the steroid cholesterol ring. Shake well for susp (acetate).
Immunosuppressives
Class Summary
Inhibit cell-mediated and (to a lesser degree) humoral immunity by arresting T-lymphocyte activity. The ultimate goal is to suppress inflammation.
Methotrexate (Folex PFS, Rheumatrex)
Antimetabolite that inhibits dihydrofolate reductase, thereby inhibiting DNA synthesis in rapidly replicating cells. Immunosuppressive actions may be related to reduction in cytokines. Available as 2.5-mg pills.
Mycophenolate (CellCept, MMF, Myfortic)
An inhibitor of inosine-5'-monophosphate dehydrogenase which secondarly depletes guanosine nucleotides preferentially in T and B lymphocytes resulting in immunosuppression.
Cyclosporine (Sandimmune, Neoral)
A cyclic polypeptide produced as a fungus metabolite, capable of reversibly arresting the T-lymphocyte cell cycle in the G0 and G1 phases. Potent down-regulator of interleukin 2 production and receptor expression. Newer Neoral preparation is better absorbed and may require marked dosage reductions.
Azathioprine (Imuran)
Antagonizes purine metabolism and inhibits synthesis of DNA, RNA, and proteins. May decrease proliferation of immune cells, which results in lower autoimmune activity.
Histamine H2-receptor antagonist
Class Summary
Reduces postprandial daytime and nighttime gastric acid secretion by about 50-80%. May increase gastromucosal defense and healing in acid-related disorders (ie, stress-induced ulcers) by increasing production of gastric mucus, increasing mucosal secretion of bicarbonate and gastric mucosal blood flow as well as increasing endogenous mucosal synthesis of prostaglandins. Histamine H2-receptor antagonists can be used prophylactically to prevent gastritis and ulcer disease in patients taking oral or intravenous corticosteroids.
Cimetidine (Tagamet)
Used as prophylaxis against corticosteroid induced gastric and duodenal ulcer.
Consult with internist if patient has preexisting symptoms of GERD or peptic ulcer disease prior to beginning corticosteroid therapy.
Ranitidine (Zantac)
Used as prophylaxis against corticosteroid-induced gastric and duodenal ulcer.
Gastric pump inhibitors
Class Summary
Thought to be a gastric pump inhibitor in that it blocks the final step of acid production by inhibiting the H+/K+ -ATPase system at the secretory surface of the gastric parietal cell. Both basal and stimulated acid secretions are inhibited. Short-term (4-8 wk) treatment of active duodenal ulcer, active benign gastric ulcer, erosive esophagitis (all grades), and heartburn and other symptoms associated with GERD.
Omeprazole (Prilosec)
Decreases gastric acid secretion by inhibiting the parietal cell H+/K+ -ATP pump.
Lansoprazole (Prevacid)
Inhibits gastric acid secretion.
Esomeprazole magnesium (Nexium)
S-isomer of omeprazole. Inhibits gastric acid secretion by inhibiting H+/K+ -ATPase enzyme system at secretory surface of gastric parietal cells.
DMARDs, TNF Inhibitors
Adalimumab (Adalimumab-atto, Amjevita, Humira)
A fully humanized anti-TNF alpha antibody FDA-approved for the treatment of intermediate uveitis, posterior uveitis, and panuveitis.
Corticosteroid Ophthalmic Implants
Fluocinolone intravitreal implant (Retisert, Yutiq)
The implants are surgically inserted by the ophthalmologist and indicated for chronic, noninfectious uveitis of posterior segment of eye. Retisert releases 0.6 mcg/day initially; amount released decreases after the first month to 0.3-0.4 mcg/day over ~30 months. Yutiq releases at a rate of 0.25 mcg/day over ~36 months.
Dexamethasone intravitreal implant (Ozurdex)
The implant is surgically inserted by the ophthalmologist and indicated for chronic, noninfectious uveitis of posterior segment of eye.
