Low-dose corticosteroid targets acute allergic conjunctivitis

Orangeburg, NY-The low-dose modified corticosteroid loteprednol etabonate ophthalmic suspension 0.2% (Alrex, Bausch & Lomb) is effectively used during the acute phase of seasonal allergic conjunctivitis, according to Ayman Matta, MD, PC, FACS.

In this situation, Dr. Matta prescribes low-dose loteprednol for use up to six times a day during the first few days of treatment, then four times a day for 2 weeks, and finally tapered to twice a day once symptoms are under control.

"That usually takes care of all of their symptoms," Dr. Matta added.

With a specific subset of patients, routine use of antihistamines is not enough to achieve symptom control, so they continue to take low-dose loteprednol for months at a time, with regular monitoring because of the potential for side effects. However, none have occurred.

"I have not seen any IOP spikes with the low-dose loteprednol or any cataract formation," Dr. Matta said.

"By starting the treatment with the low-dose loteprednol and the antihistamine together, patients whose symptoms have not responded to previous treatment get very rapid relief," he added. For most patients, steroid treatment can be tapered off fairly quickly, while others continue to take it for months.

He also mentioned that low-dose loteprednol contains a small amount of glycerin, which enhances patient comfort when using the drops and is especially beneficial when the patient has both dry eye and allergic conjunctivitis and may be unable to tolerate agents that further dry the eye, such as antihistamines.

Treating chronic red eyes

Loteprednol 0.2% is also useful for many patients with chronic red eyes.

"I see a lot of patients who have chronic red eyes, and the only thing that would control it would be a steroid," Dr. Matta said. "Obviously if I give them a traditional steroid like prednisolone (Pred Forte, Allergan) it would help the red eye, but it has a lot of side effects. Loteprednol 0.2% has a 4-year published record of safety data, so I think that low-dose loteprednol would be sufficient to control their symptoms. I feel very comfortable treating patients with it for a while. I haven't seen significant side effects from it."

Unlike more powerful corticosteroids, low-dose loteprednol is very rapidly degraded into inactive metabolites by the esterases in the eye. This allows it to have an effect on symptoms but not linger in the system long enough to produce side effects such as elevated IOP or cataract formation, Dr. Matta said.

"In many patients, I feel that if steroids are indicated or needed to control allergy symptoms, low-dose loteprednol works by several different mechanisms," he continued. "First, it works on the proinflammatory mediators and interruption of transcription. That will lead to regulation of the histamine production levels from the cells. It also works on the late phase of the inflammatory cascade by inhibiting the precursor molecule, which is phospholipase A1. By doing that you inhibit all the late stages of inflammation, for example chemosis, lid swelling, and the chronic irritation that allergic patients get."