Category Archives: Uncategorized

Review on Breast Cancer guidelines

downloadThe origination of malignant cells in the ducts of breast or the milk-producing glands can lead to what we call breast cancer.

Recommendations by American Cancer Society (ACS):

  • Regular screening through mammography (at 45 years of age) for all those women who carry a risk of breast cancer (strong recom.)
  • Annual screening for the rest of the population who fall among the age group of 45-54 years (qualified recom.)
  • Two-yearly or annual screening for 55 years and above-aged women (qualified recom.)
  • No clinical breast examination for breast cancer screening among average-risk women at any age (qualified recom.)

Process for guideline development:

GDG (guideline development group) comprising of clinicians, epidemiologists, patient representatives, economists, and biostatisticians was formulated for the guideline advancements. The recommendations were categorized as “qualified” or “strong”, with qualified ones carrying a clear substantiation of advantage but the lesser clear conclusion about either the ratio of benefits and harms or about patients’ values, whereas a strong reference ensures the outweighing of benefits.

Issues tackled up in the guideline review:

  • Benefits and harms of having a clinical breast examination (CBE) among average-risk women who are 20 years and older compared with those who have never undergone CBE.
  • Benefits, and harms in going through various screening methods in comparison with no screening among women in whom the heightened risk is already identified due to certain factors such as family history, chest irradiation history, a carrier of BRCA mutation.
  • Benefits and harms associated with mammography compared with no screening.
  • Variations in results due to age, screening history, or screening intervals.
  • Benefits and harms associated with different screening modalities at different intervals, and in different age groups.
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Patient information on Suboxone (buprenorphine and naloxone)

 

 Here the word Drug would be referred to a narcotic substance.

Manufacturing company: Indivior Inc.

Uses of Suboxone: it is used for treating the patients who are addicted to opioids (morphine, heroin) or abuse such drugs. This medicine is a part of the treatment of opioid dependence along with behavioral and psychological education and counseling. If you have an addiction problem it does not mean that you are a wrong or a bad person but it is important to understand that it is okay to talk about it to your family, and seek proper clinical help as there are now various treatments available in this respect.   

You should be aware of the adverse effects of a drug addiction. It leads to the development of violent behavior, theft, physical, psychological problems, illegal activities, various health problems, transmission of diseases due to the use of contaminated syringes and needles, family and work-related complications, accidents, overdosing and death. Suboxone is indicated for people who have become addicted to heroin, morphine, codeine, oxycodone, and fentanyl.

Factors or conditions that usually play role in a person becoming addicted to illegitimate drugs involve;

Stress which could be either family or work related, community where drugs are sold and abused, joblessness, people who have a rough childhood and have an abusive child life, whose parents or siblings or spouse abuses drugs, self-diagnosis and self-medication with drugs that can have effects on mental health, people with an underlying mental or a psychological illness, deficit in neurotransmitters in brain e.g. endorphin.

Dosing of Suboxone: it should be taken into account that this medicine can only be prescribed by those doctors who are registered under DATA (drug addiction treatment act) and Suboxone will be prescribed to you by taking into account various clinical and behavioral factors. You should only take Suboxone in quantities as guided by your doctor and should never taper the dose by yourself.

 

The regimen is usually altered and adjusted by monitoring;

  • the event that the patient has been securely and proficiently taking care of the medicinal use
  • Has not experienced any sort of adverse effects concerning physical and mental health
  • Has not been overdosing or abusing the medicine
  • Has undergone improvements.
  • Has been following the treatment properly and regularly as instructed.

Correct administration:

  • Always put the whole intact in the mouth. Do not chew or swallow it.
  • Do not eat anything while you have placed Suboxone in the mouth, for the prevention of an accidental swallow.
  • Buccal administration: place the tablet inside the cheek on either side. If more than one tablet is to be placed, place one tablet in the right cheek and another tablet in the left cheek. Do not move the tablets from their place after placing them inside. Let them stay until completely dissolved.
  • Sub-lingual administration: place one film on either right or left side under the tongue until dissolved. If you need to place another film along with it for adequate dosing (prescribed by the doctor) put it on the opposite side under the tongue, ensuring that they do not touch or join each other.
  • If you are supposed to place a 3rd tablet or film, administer it after one side has dissolved.
  • You can easily switch from sub-lingual to the buccal site of administration without risking the fluctuation in the dosage levels.
  • But do not switch strengths and potency of the product without consulting your respective doctor as the concentrations of the agents can vary and lead to unwanted effects.

Suboxone in special populations:

  • In pregnancy: it falls under the category C. It should only be used under the supervision and recommendations of the specified doctor.
  • During lactation: buprenorphine gets excreted in human milk and so should be used if the benefits of taking the medicine are more than its risks. Monitor your baby for increased lethargy, or any breathing problems.
  • In children: it should not be used by young kids due to the danger of respiratory failure.
  • In older people: although considered safe should be started at lowest doses possible.
  • In liver failure: Suboxone can cause hepatitis, jaundice, damage to the liver cells (necrosis), which leads to lesser clearance and enhanced exposure of Naloxone. As it is a combination dosage form and the dose of a single agent can’t be adjusted alone, hence, Suboxone should be avoided in patients having a moderate-severe liver failure.
  • In unstable patients: people who do not respond to the medication or start abusing it are transferred to the rehabilitation centers.

Contra-indications to Suboxone use:

  • Promptly contact restorative help if on taking Suboxone you face breathing challenges, swelling, rash, blushed skin, hives as it is the indications of a hypersensitive response to the medication.
  • Do not give Suboxone to children as it is could produce fatal breathing issues in them. Always make sure the medicine is placed in a secure place away from the child’s reach.
  • Suboxone is not for pain relieving use specifically in people who are opioid naïve i.e. have not used any kind of opioid preparation in the past.

Precautions and Warnings related to Suboxone:

  • You should always take Suboxone as described by your doctor. Taking it in increased amounts can lead to addiction as well. You will be kept under supervision during the initiation of the treatment. You should talk to your doctor if you start experiencing addictive behavior towards Suboxone which may include joyousness and euphoria, the presence of many multiple Suboxone packages in the house, decreased desire for other opiates (heroin, morphine etc.), need for regular refills of Suboxone, distracted and unusual behavior.
  • You should not self-inject CNS depressants such as benzodiazepines, anesthetics, or consume alcohol, tranquilizers with Suboxone as it could result in severe respiratory collapse, nervous system shut down, coma and even death.
  • You should never discontinue Suboxone on your own as an abrupt stoppage of the medication can cause severe withdrawal symptoms such as nausea, vomiting, weariness, aggression, muscle pain, sleeplessness, restlessness, nervousness, and headache.
  • It should be given with extreme care if the patient has stomach issues and disorders, if alcoholic, has bile malfunction, cranial injuries, breathing problems.
  • Do not drive after taking Suboxone. Prevent doing heavy machine work as well.
  • Neonatal opioid withdrawal syndrome (NOWS): babies who are born to women who abuse opioids suffer from NOWS which includes severe diarrhea, non-stop crying, convulsions, sleep disturbances, tremors, sneezing, fever, and increased tone of muscle.

Adverse effects:

Suboxone can cause the following side effects;

Withdrawal symptoms, weakness, diarrhea, chills, vomiting, nausea, edema, swelling, respiration problems, pain, insomnia, constipation, excessive sweating, cough, headache, infections, abdominal aches, inflammation of the tongue, oral cavities.

Drug interactions:

  • With benzodiazepines: use of Suboxone with such agents leads to shut down of the respiratory systems.
  • With anti-retroviral: decreased dose of buprenorphine is used with Protease inhibitors like ritonavir and atazanavir. No adjustments are required with Nucleoside reverse transcriptase inhibitors. Non‐nucleoside reverse transcriptase inhibitors such as delavirdine, nevirapine, efavirenz, etravirine can increase or decrease the Suboxone levels in plasma.
  • With CYP3A4 affecting agents: Suboxone should be used carefully with medicines that can induce or inhibit these enzymes as the inhibition could lead to increased levels of Suboxone and increased sedation whereas the induction can lead to low levels and sub-therapeutic effects. You can contact your pharmacist to know which drugs come under this category.

Mode of action:

Naloxone: it is a strong antagonist at mu opioid receptors

Buprenorphine: it is a partial agonist and partial antagonist of mu, delta receptors and kappa opioid receptors respectively.

Mu receptors when activated can cause relief in pain, low blood pressure, itching, euphoria, sedation, nausea, constipation, reduced respiration, and constricted pupils.

Delta receptors cause physical dependence, intense happiness, and convulsions.

Kappa produces depression, dysphoria (extreme sadness), lethargy, stress, constriction of the pupils.

Absorption: Suboxone undergoes full absorption after 0.77-0.81 hours for naloxone and 1.53-1.72 hours for buprenorphine.

Distribution: naloxone binds to the albumin whereas buprenorphine binds to alpha and beta globulin proteins of the plasma.

Metabolism: naloxone undergoes metabolism through glucuronidation whereas buprenorphine is subjected to CYP3A4 enzymes.

Excretion: it gets removed from the body through feces and urine.

Storage: store it at room temperature at a place where children can’t reach the product.

Ingredients: buprenorphine and naloxone, sodium citrate, lime flavor, Sunset Yellow FCF and a white printing ink, hypromellose, acesulfame potassium, citric acid, polyethylene oxide, and maltitol solution.

Toxicity:

  • It did not produce any changes in the genetic makeup of the animals during pre-clinical studies.
  • Suboxone decreased the rate of pregnancy in female rats.
  • It also up the levels and rates of adenomas in rats.

 Inform your doctor:

Before starting treatment with Suboxone, inform your doctor of the following;

  • Time length of your addiction
  • How and when you got addicted
  • If you abuse any other drugs apart from opioids
  • If you suffer from psychological disorders
  • About respiratory problems if any
  • If has a liver disease
  • If pregnant or
  • Breast-feeding

 

 

Patient Information on EPIDUO (adapalene and benzoyl peroxide gel)

Manufactured by: Galderma Laboratories, L.P.

Use of Epiduo: we all suffer from acne now and then.  Acne is a very common problem, especially among younger people. Acne means the development of red spots, pimples, and blemishes on the skin. The skin of the face, arms and back are the sites which usually get affected. Despite the fact that they vanish all alone yet now and again can get pustulated and erupt, this emits and deserts a dreadful scar. You may wonder why these horrid bulges get formed on the body, well the answer is simple. Due to the blockage of the sebaceous glands present in our skin which is responsible for the production of oil gets infected by the adjacent germs. Also, pubescence doesn’t help the condition either… hormones, for example, androgens increase during the adolescence and triggers these glands to produce more sebum.

And here comes the Epiduo gel for the treatment of acne vulgaris in patients of 12 years and more. It is manufactured as an aqueous based gel containing 25 mg of benzoyl peroxide and 1 mg of Adapalene.

Administration: the right way of applying the gel is given below;

  • Wash your hands every time before applying the gel.
  • Take out a very small quantity of the gel and apply it on the skin having pimples.
  • Repeat this process once daily after washing.
  • When on treatment with Epiduo, do not subject to waxing or epilating.
  • Ensure you don not insert it into the eyes, nose or mouth. The gel should not be applied in the vagina for any comparable condition.
  • Place the container in a cool and dry place which will not come in contact to direct light and will be away from the children’s reach.

Use in other populaces:

  • Pregnancy: it falls in the category Abstain from using this medicament during pregnancy as none trials or tests have been conducted with Epiduo gel neither in animals nor in human.
  • Breast-feed: should not be used during the lactating period as it is not known whether the agents present in this gel get secreted into the mother’s milk or not.
  • Pediatrics: not safe for youngsters less than 12 years old.
  • Geriatrics: more studies need to be conducted to determine the effectiveness and safety in older patients.

Warnings:

  • Application of this gel should be avoided in the case of hypersensitivity to the ingredients used in it.
  • During the first few weeks of initiation of the application of the gel can cause your skin to burn, sting, dry or itch. Try using a moisturizer to abate these reactions. If you feel that these impacts are deteriorating, end the gel and counsel your skin expert.
  • You should not apply the gel more than one time a day or in larger quantities.
  • Do not apply the gel on the areas of the skin which are broken, scratched, wounded, burnt, or bleeding.
  • Avoid using Epiduo with medicated soaps, lotions or cosmetics, which could otherwise prompt more intense irritation.
  • Stay away or protect your skin from coming in direct contact with the sunlight and sunlamps. Use sunscreen and wear proper protection for it.
  • Attempt to go less outside when the climate is extremely cool or excessively hot as the atmosphere furthest points can also play a role in irritating your skin.
  • The contents of Epiduo gel can fade the color of the clothes and hair.

Interactions with other medicines:

You should not apply other preparations for acne with Epiduo as it could cause severe irritation and inflammation of the skin.

Adverse reactions: most of the side effects appear on the skin, such as scarring, redness, allergic reaction, burning, stinging, blistering, swelling, sunburns, rash, discoloration, dryness of the skin. Apart from the skin-related side effects, Epiduo can also cause eye infection, swelling of the eyelids, scratchy and irritation in the throat.

Toxicology: toxicology provided details regarding Epiduo gel in general are not present but rather such tests have been led by the individual agents. Following results were found in animals;

  • Benzoyl peroxide: does not itself cause tumors but rather acts as a marker or supporter to other carcinogens (cancer causing substances). It was also found to be able to cause changes in the DNA of the human lung cells.
  • Adapalene: it did not transform the reproductive functioning of the rats and mice and also didn’t cause any genetic aberrations in them but it did cause tumors in the adrenal glands of the male rats.

Mode of performance:

  • Adapalene: exact method how it fights acne is not determined. But it brings down inflammation by acting upon the retinoic receptors and suppressing the inflammatory processes.
  • Benzoyl peroxide: it targets the bacteria infecting the skin and glands by releasing free oxygen radicals that scavenge these bugs.

Absorption and secretion: benzoyl peroxide on assimilation from the skin is initially changed into benzoic acid. Benzoyl peroxide and adapalene are excreted through the urine and bile, respectively.

Before using Epiduo inform your doctors: if you are pregnant or had a delivery and if breast-feeding.

Ingredients: adapalene and benzoyl peroxide, purified water, sorbitan oleate, edetate disodium, glycerin, isohexadecane, acrylamide/sodium acryloyldimethyltaurate copolymer, docusate sodium, poloxamer 124, polysorbate 80, propylene glycol.

Patient Information on ULORIC (febuxostat)

 Manufacturing company: Takeda Pharmaceuticals America, Inc.

What is Uloric? It is a uric acid lowering agent used for the treatment of gout. It is not to be confused with Xyloric.

Alterations or switch from the normal metabolic formation and excretion of the uric acid leads to an accumulation of increased levels of urate in the joints which causes severe pain and if left untreated can result in tophy i.e. deformation of the bones and joints.

What is its dosage form? It is marketed in a form of tablets with different potencies. The 40mg tablet is round whereas an 80mg tablet is tear-shaped.

What should you know about Uloric?

  • Do not confuse it with Xyloric which sounds alike but has a different active agent.
  • You can take it before or after the meal. Swallow it whole. Do not break or chew the tablets.
  • You can use Uloric irrespective of the gender.
  • After two weeks of starting the treatment with Uloric, you will need to have your uric acid levels tested.
  • Not only the increased levels, but the decrease and fluctuation and movement of the urate can cause pain and inflammation termed as gouty flares. Your doctor will prescribe you NSAIDs (analgesics) for the prophylactic purposes against the gouty flares. Although Uloric can be taken on an empty stomach, do not take NSAIDs empty stomached.
  • Along with medication, you will also require dietary modification in gout such as reduced use of meat, dairy products, fizzy drinks etc. Consult a dietician in this respect.

Can Uloric be used in different patient populations?

In pregnancy: it is placed under the category C because no adequate and well-structured tests have been conducted in this regard. It should be used with great care in such women, only when truly needed.

In nursing mothers: test on rats have revealed the presence of Uloric in the milk but it is not yet known if the case is same in humans. However, it should be used by breast-feeding mothers with caution and on the advice of the doctor.

In children: it is not for use in children under 18 years.

In geriatrics: it is safe to be used by elderly.

In liver injuries: Uloric can be easily used in mildly damaged liver but not in severe hepatic impairments.

In kidney failure: Uloric does not require any specific considerations in moderately affected kidney function, but should not be taken if your kidneys are majorly compromised.

In asymptomatic hyperuricemia:  Uloric is not used if you have high levels of uric acid in your body but have no apparent symptoms yet.

In secondary hyperuricemia: if the raised uric levels are result to an organ transplant, Uloric can be used only if guided by professional medical personnel.

What are its contra-signs or precautions?

  • Uloric can cause varying cardiovascular symptoms, talk to your doctor if you experience any chest pains, breathlessness, fatigue, palpitations.
  • Uloric can also lead to liver failure. If you develop any signs of weight loss, loss of appetite, extreme tiredness, yellowing of the skin, upper abdominal pain, dark colored urine, consult your doctor and have your liver functioning tests. Your doctor may ask you to stop Uloric until and unless any other cause of the liver abnormality is discovered.
  • Uloric is highly forbidden if you are undergoing chemo treatment with mercaptopurine or azathioprine.
  • Uloric on initial treatment stages can produce bouts of inflammation and pain in the joint which is managed by the use of NSAIDs as prescribed.

What are its various drug-interactions?

Mercaptopurine and azathioprine: Uloric is never to be used concomitantly with these high alert medications as it increases their levels by affecting their metabolism in the body.

Theophylline: it changes the metabolic processes of theophylline because theophylline is metabolized via xanthine oxidase and Uloric inhibits the enzyme.

Others: Uloric has no effect with warfarin, desipramine, indomethacin, hydrochlorothiazide, colchicine, and naproxen.

 What are its side effects?

Uloric gives following adverse effects; Abnormal levels of liver enzymes, nausea, rashes on the skin, painful muscles, muscle protein breakdown, anaphylaxis, aggression, inflammation of nephrons, eruptions on the skin.

What are the components present in the tablets? It has febuxostat, microcrystalline cellulose, silicon dioxide, hydroxypropyl cellulose, sodium croscarmellose, lactose monohydrate, and magnesium stearate.

What are its storage requirements? Place the tablets at a room temperature in a place where it is protected from the direct light.

What is the toxicology report of Uloric? When the rats and mice were given 25 times the human dose of Uloric, it caused bladder cancer in female rats and epithelial tumor in male rats. It had no effect on their reproductive functions but came out positive for chromosomal mutation tests.

What should you inform your doctor about?

Before starting Uloric tell your doctor if you have any;

Kidney, liver, heart disease, cancer or taking anti-cancer medications, a history of stroke.

What is its mode of action?

It is an inhibitor of enzyme xanthine oxidase. This enzyme is involved in uric acid synthesis by transforming hypoxanthine to xanthine and then finally to uric acid. On inhibition of this enzyme by Uloric, more uric acid is not formed.

What is its absorption, distribution, metabolism and excretion profile?

Absorption: it reaches its full plasma concentrations after 1-2 hours.

Distribution: almost whole drug gets bind with the proteins in the plasma which helps in its transportation. It has a distribution volume of 50L.

Metabolism: it is metabolized by both CYP450 enzymes and non-cytochrome enzymes.

Excretion: it is removed from both urine and feces.

Diabetic Peripheral Neuropathy

neuropathy-foot

Introduction: diabetes is one of the most common health problems in the world which requires proper therapeutic attention otherwise it could result in long term macro vascular and micro vascular complications. About 50% of diabetic patients develop long term complications. The most common type of neuropathy which accounts for 75% of diabetic neuropathy is the diabetic sensorimotor polyneuropathy defined as a diffused symmetrical and length dependent injury to peripheral nerve fibers.  It commonly goes by the name of diabetic peripheral neuropathy (DPN). It causes pain and loss of sensation in hands, arms, fingers, toes, legs, feet and it is the major reason for non-traumatic lower limb amputations. Diabetic peripheral neuropathy is different from peripheral arterial disease (poor circulation), which affects the blood vessels rather than the nerves.

Etiology: various vascular factors and changes in metabolism (e.g. hyperglycemia, dyslipidemia) is the reason for the development of DPN. Impaired flow of blood and endoneurial hypoxia is one of the major contributing factors.

Clinical Presentation: mostly it is asymptomatic with only 10-20% of patients requiring intervention. The onset is usually gradual and presents as a painless loss of sensation. Newly diagnosed patients with Diabetes type 2 will present with some type of DPN at the time of diagnosis. Sensory symptomatology is of more significance as compared to the motor involvement. The unsteadiness which leads to balance problems and consequently increases the risks for falls is due to numbness and abnormal muscle sensory function.

The neuropathic pain is characterized by burning, electrical, stabbing feeling. The pain could worsen at night and could lead to sleep disturbances.

Management: two aspects are focused while treating DPN i.e. resolving the underlying cause and the relief of symptoms. The first one is usually achieved by tightly and effectively managing the patient’s glucose levels.

Pharmacologic agents: agents recommended by American Academy of Neurology (AAN) guidelines 2011 include;

DRUG DOSAGE
Anti convulsants
Pregabalin 300-600 mg/day
Gabapentin 900-3,600 mg/day
Sodium valproate 500-1,200 mg/day
Anti depressants
Amitriptyline 25-100 mg/day
Duloxetine 60-120 mg/day
Venlafaxine 75-225 mg/day
Opioids (for patients not responding to other options)
Morphine sulfate Up to 120 mg/day
Oxycodone Up to 120 mg/day
Tramadol 210 mg/day
Other
Capsaicin 0.075% Four times daily

Reference:

  • American Academy of Neurology (AAN) guidelines 2011.

 

Non 24 hour Sleep Wake disorder

ritmul-circadian

Tau: an individual’s circadian period is a tau. Light is the strongest stimuli for the synchronization to 24 hours sleep wake cycle. At dim light, melatonin gets released from the pineal gland signaling the body of sleep time.

Disorder: Non 24 is one of the four endogenous circadian rhythm sleep disorder (CRSD). It occurs when the person’s circadian rhythm is not entrained with the environment’s 24 hour sleep wake cycle. Irregular sleep disorder leads to insomnia and daytime sleep.

Symptoms: varies  from patient to patient, and most complaints are of disrupted night time sleep, daytime nap and  irritability.

Diagnosis:  minimal criteria consists of a complaint in  falling asleep or rising up, delayed sleep cycle with a more than 6 weeks of this irregulation. It is most commonly found in blind patients.

Treatment approaches:

  • It is not just a sleep disorder but a circadian rhythm disorder so the therapy or treatment is more complex than just the use of  hypnotics and sedatives.
  • Underlying causes require equal attention and needs to be resolved as well.
  • Light therapy is done for 2-3 hours daily.

 Endogenous CRSD:

Disorder

Characteristics
Advanced sleep phase disorder A stable sleep schedule several hours earlier than desired normal.
Delayed sleep phase disorder Later than conventional
Irregular sleep wake rhythm Sleep times shortened & randomly distributed throughout the day. Commonly seen  in neurologic impairments.
Non 24 hour sleep wake disorder Sleep cycle shifts in & out of sync.

 

Pharmacological options:

Drug Dosage Regimen Duration of use
Melatonin 10mg Daily 3-9weeks or more
Tasimelteon 20mg capsules 1 hour before bed time, at the same time every night 6months
Vit B12 500, 1000, 5000mcg 1-3 times daily 5 days-2 years.

Age Related Macular Degeneration (ARMD)

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Definition: it is the degenerative disease of the central part of retina known as macula, characterized by a loss of visual acuity, retinal pigment epithelium (RPE) and photoreceptors.

Classification of ARMD:  

Designation Description

No ARMD

No or few small drusen
 Early Multiple small drusen or RPE abnormality
Intermediate Extensive inter drusen, large drusen

Advanced

Atrophy or neovascular maculopathy

Drusen: Is a tiny yellow or white accumulation of extracellular material in Bruch’s membrane of the eye. Drusen can also be defined as deposits of extracellular debris between basal lamina of RPE & inner collagenous layer of Bruch’s membrane. These lesions are hallmark of ARMD. They can be hard or soft. Soft drusen  are larger & have no well-defined margins. Whereas hard drusen’s are smaller & well defined. Drusen is composed of lipids, carbohydrates, zinc & proteins.

Stages of ARMD: early stages are characterized by macula with yellowish sub retinal deposits and increased pigmentation.

Types:

  • Dry ARMD also known as non exudative, non neovascular or atrophic ARMD. Is more common & has slow progression.
  • Wet ARMD also called exudative & neovascular ARMD. It has rapid distortion & a sudden loss of central vision. Macular edema due to accumulation of fluid underneath retina can also be seen.

 Etiology & risk factors: are multifactorial and involves genetics, environment, metabolics, family history, smoking, blood pressure etc. Macular deterioration destroys central vision but peripheral vision remains intact.

Diagnosis: ARMD is usually asymptomatic but acute vision loss may occur. As it has a slow progression, so routine dilated eye exams are recommended.  13% patients with ARMD present with Charles Bonnet syndrome, in which healthy patients have vision loss & visual hallucinations.                                                                                                                                      Tests:  Visual acuity tests, dilated fundoscopy, fundus autofluorescence are done.

Treatment: Thermal laser photocoagulation was choice of treatment, but was seen to be associated with high rate of recurrence.

Submacular surgery, external beam irradiation, I/V steroids for their anti angiogenic effect have more side effects & lesser use.

Better options include;

PDT… Photodynamic therapy which uses a combination of drugs & laser. Verteporfin forms free radicals, coagulating retinal damaging vessels. It is reconstituted with WFI to give 7.5ml containing 2mg/mL. Contraindication to verteporfin is porphyria.

VEGF inhibition: Vascular endothelial growth factor inhibitors for angiogenesis being used are Bevacizumab (Avastin), ranibizumab intravitreally.