Anti-inflammatory Drugs — MCQs
Atropine is the drug of choice in –
All are drugs which lower IOP except:
A patient diagnosed with Rheumatoid arthritis was on medications. After 2 years, he developed a blurring vision and was found to have corneal opacity. Which drug is most likely to cause this?
Primary objective of the use of atropine in anterior uveitis
Which of the following nonsteroidal anti-inflammatory drugs (NSAIDs) has good tissue penetrability with a concentration in synovial fluid?
Cyclosporine is used in the management of -
NSAID used commonly for topical ocular use is
A 30-year-old female presents with redness and pain in the eye. Examination revealed 38 mm of Hg on IOP, aqueous flare, and corneal precipitates. Which of the following drugs must be avoided for her?
Which enzyme is primarily inhibited by the drug prednisolone, leading to its anti-inflammatory effects?
Which of the following drugs possesses similar cycloplegic action and is a more potent mydriatic than atropine?
Anti-inflammatory Drugs Indian Medical PG Practice Questions and MCQs
Question 1: Atropine is the drug of choice in –
- A. Chorioretinitis
- B. Lens induced glaucoma
- C. Iridocyclitis (Correct Answer)
- D. Closed angle glaucoma
Explanation: ***Iridocyclitis*** - Atropine is a **potent cycloplegic and mydriatic agent** often used in iridocyclitis to **relax the ciliary body muscles** and prevent the formation of posterior synechiae. - Its **long-acting effect** helps in reducing pain, inflammation, and preventing complications such as iris bombe by keeping the pupil dilated. *Chorioretinitis* - This condition primarily affects the **choroid and retina**, and while inflammation may be present, systemic or topical **corticosteroids** are typically the primary treatment. - Atropine is not indicated as a primary treatment for the inflammation itself in chorioretinitis, as its main action is on the iris and ciliary body. *Lens induced glaucoma* - The definitive treatment for lens-induced glaucoma, such as **phacomorphic glaucoma** or **phacolytic glaucoma**, is surgical removal of the cataractous lens. - Atropine would cause mydriasis, which can paradoxically worsen some forms of glaucoma by blocking the drainage angle, especially in cases of angle closure [1] [2]. *Closed angle glaucoma* - Atropine, being a mydriatic, would **dilate the pupil** and potentially exacerbate closed-angle glaucoma by further **crowding the anterior chamber angle** and blocking aqueous humor outflow [3]. - The focus in closed-angle glaucoma is to constrict the pupil (with miotics like pilocarpine) and reduce intraocular pressure.
Question 2: All are drugs which lower IOP except:
- A. Mannitol
- B. Clonidine
- C. Acetazolamide
- D. Dexamethasone (Correct Answer)
Explanation: ***Dexamethasone*** - Dexamethasone is a **corticosteroid** that is known to increase **intraocular pressure (IOP)**, particularly with prolonged use, in susceptible individuals. - This increase in IOP is a significant side effect and can lead to **steroid-induced glaucoma**. *Mannitol* - **Mannitol** is an osmotic diuretic that rapidly reduces IOP by creating an osmotic gradient, drawing water out of the eye. - It is often used in acute settings for rapid reduction of **high IOP**, such as in acute angle-closure glaucoma. *Clonidine* - **Clonidine** is an alpha-2 adrenergic agonist that lowers IOP by reducing aqueous humor production and possibly increasing uveoscleral outflow. - While not a primary glaucoma medication, it has been shown to have an **IOP-lowering effect**. *Acetazolamide* - **Acetazolamide** is a carbonic anhydrase inhibitor that significantly reduces IOP by decreasing the production of aqueous humor. - It is a cornerstone medication for managing **glaucoma** and other conditions requiring IOP reduction.
Question 3: A patient diagnosed with Rheumatoid arthritis was on medications. After 2 years, he developed a blurring vision and was found to have corneal opacity. Which drug is most likely to cause this?
- A. Sulfasalazine
- B. Leflunomide
- C. Chloroquine (Correct Answer)
- D. Methotrexate
Explanation: ***Chloroquine*** - **Chloroquine (and hydroxychloroquine)** can accumulate in the **cornea**, leading to **corneal opacity** (vortex keratopathy or cornea verticillata) and **retinopathy**, manifesting as blurring vision. - While corneal changes are usually reversible upon discontinuation, the retinal toxicity, particularly **maculopathy** (bull's eye maculopathy), can be permanent and severe. *Sulfasalazine* - Common side effects include **gastrointestinal upset**, headache, skin rash, and **bone marrow suppression**. - It is not typically associated with **corneal opacity** or significant ocular toxicity. *Leflunomide* - Known for side effects such as **hepatotoxicity**, gastrointestinal issues (diarrhea), **alopecia**, and **hypertension**. - **Ocular side effects** like corneal opacity are not characteristic of leflunomide use. *Methotrexate* - Primary side effects include **bone marrow suppression**, **hepatotoxicity**, **mucositis**, and **pulmonary fibrosis**. - Although it can cause ocular side effects like **conjunctivitis**, it is not a common cause of **corneal opacity**.
Question 4: Primary objective of the use of atropine in anterior uveitis
- A. Rest to the ciliary muscle (Correct Answer)
- B. Helps in preventing posterior synechia formation
- C. Increase blood flow
- D. Increase supply of antibody
Explanation: ***Rest to the ciliary muscle*** - Atropine is a **cycloplegic** agent that paralyzes the **ciliary muscle**, thereby alleviating pain caused by spasms and inflammation in anterior uveitis. - This **cycloplegia** is the primary therapeutic goal, as it reduces **ciliary spasm** and the associated pain. *Helps in preventing posterior synechia formation (secondary effect)* - While atropine's **mydriatic** action (pupil dilation) helps prevent the formation of **posterior synechiae**, this is a beneficial secondary effect and not its primary objective in alleviating symptoms or pain. - The dilation breaks existing synechiae or prevents new ones from forming by moving the iris away from the lens capsule. *Increase blood flow* - Atropine's primary action is anticholinergic, leading to **cycloplegia** and **mydriasis**, not a direct increase in ocular blood flow. - Increased blood flow is not a targeted therapeutic effect of atropine in acute anterior uveitis. *Increase supply of antibody* - Atropine does not directly influence the immune system or increase the supply of antibodies to the inflamed eye. - Its mechanism of action is limited to blocking muscarinic acetylcholine receptors.
Question 5: Which of the following nonsteroidal anti-inflammatory drugs (NSAIDs) has good tissue penetrability with a concentration in synovial fluid?
- A. Ketorolac
- B. Diclofenac sodium (Correct Answer)
- C. Piroxicam
- D. Sulindac
Explanation: ***Diclofenac sodium*** - **Diclofenac** is known for its excellent **tissue penetration**, achieving concentrations in **synovial fluid that approach or exceed plasma levels** within hours of administration. - This **rapid and efficient synovial accumulation** makes it particularly effective for **acute inflammatory joint conditions** such as rheumatoid arthritis and osteoarthritis. - Its **favorable pharmacokinetic profile** combines good penetration with relatively rapid onset of action in joint tissues. *Ketorolac* - While a potent NSAID often used for **acute pain management**, ketorolac does not specifically demonstrate superior synovial fluid penetration compared to other NSAIDs. - It has a relatively **short half-life** and is typically limited to **short-term use** (≤5 days) due to increased risk of adverse effects with prolonged administration. *Piroxicam* - **Piroxicam** does achieve good synovial fluid concentrations with a very **long synovial half-life** due to its overall prolonged elimination. - However, the question specifically asks about "good tissue penetrability with concentration," and **diclofenac** is more characteristically cited for its **rapid synovial penetration** and accumulation. - Piroxicam's main advantage is **once-daily dosing** due to its long plasma half-life, rather than superior initial penetration. *Sulindac* - **Sulindac** is a **prodrug** requiring hepatic conversion to its active sulfide metabolite. - Known for potential **renal-sparing effects** in some patients, but does not demonstrate preferential or superior synovial fluid accumulation compared to diclofenac. - Its prodrug nature may result in less predictable synovial fluid concentrations.
Question 6: Cyclosporine is used in the management of -
- A. Disciform Keratitis (Correct Answer)
- B. Phacomorphic glaucoma
- C. Anterior Iridocyclitis
- D. Rhegmatogenous retinal detachment
Explanation: ***Disciform Keratitis*** - **Cyclosporine** is an immunosuppressant particularly valuable in managing **disciform keratitis**, which represents immune-mediated stromal inflammation typically associated with herpes simplex virus (HSV). - In disciform keratitis, the primary pathology is **immune-mediated** rather than active viral replication, making cyclosporine an ideal therapeutic choice to suppress the inflammatory response while avoiding steroid dependency. - **Topical cyclosporine 0.05% or 1%** is specifically indicated for this condition and represents a **characteristic indication** in ophthalmic practice. *Anterior Iridocyclitis* - While cyclosporine may be used in **chronic, recurrent, or steroid-dependent anterior uveitis**, it is not a first-line agent for typical acute anterior iridocyclitis. - First-line management involves **topical corticosteroids** and **cycloplegics**; cyclosporine is reserved for refractory cases. - Disciform keratitis remains the more characteristic and commonly tested indication for cyclosporine in ophthalmology. *Rhegmatogenous retinal detachment* - **Rhegmatogenous retinal detachment** is a surgical emergency caused by a retinal tear allowing vitreous fluid into the subretinal space. - Management is **surgical** (scleral buckle, vitrectomy, or pneumatic retinopexy); immunosuppressants like cyclosporine have no role in this mechanical problem. *Phacomorphic glaucoma* - **Phacomorphic glaucoma** is secondary angle-closure glaucoma caused by an intumescent (swollen) lens pushing the iris forward. - Treatment involves **IOP control** followed by **cataract extraction**; cyclosporine has no role in this mechanical lens-induced condition.
Question 7: NSAID used commonly for topical ocular use is
- A. Ibuprofen
- B. Ketorolac (Correct Answer)
- C. Acetaminophen
- D. Aceclofenac
Explanation: ***Ketorolac*** - **Ketorolac tromethamine** is a potent NSAID commonly formulated as an ophthalmic solution for topical ocular use. - It is effective in reducing **post-operative inflammation** and pain following ocular surgery, such as cataract extraction. *Ibuprofen* - While ibuprofen is a widely used oral NSAID, it is **not commonly available** or prescribed as a topical ophthalmic preparation. - Its primary use is for systemic pain and inflammation relief. *Acetaminophen* - **Acetaminophen (paracetamol)** is an analgesic and antipyretic but is classified as a non-opioid analgesic and generally **not considered an NSAID** due to its minimal anti-inflammatory properties through COX inhibition. - It is not used for topical ocular administration to treat inflammation. *Aceclofenac* - Aceclofenac is an NSAID used systemically for inflammatory conditions, but it is **not commonly formulated** or used as a topical ocular agent. - **Diclofenac**, a related NSAID, is available as an ophthalmic solution, but not aceclofenac.
Question 8: A 30-year-old female presents with redness and pain in the eye. Examination revealed 38 mm of Hg on IOP, aqueous flare, and corneal precipitates. Which of the following drugs must be avoided for her?
- A. Carbonic anhydrase inhibitors
- B. Prostaglandin analogs (Correct Answer)
- C. Mannitol
- D. Beta-blockers
Explanation: ***Prostaglandin analogs*** - **Prostaglandin analogs** are **contraindicated in anterior uveitis** because they can significantly worsen inflammation. - They increase the risk of **cystoid macular edema (CME)** in patients with intraocular inflammation. - Can exacerbate existing **uveitis** and compromise treatment outcomes. - While they effectively lower IOP in non-inflammatory conditions, their pro-inflammatory effects make them unsuitable when aqueous flare and KPs are present. *Carbonic anhydrase inhibitors* - These drugs work by decreasing **aqueous humor production** and are safe and effective for reducing **IOP** in **uveitis**. - They do not exacerbate inflammation and are commonly used in the management of **uveitic glaucoma**. - Available in topical (dorzolamide, brinzolamide) and systemic (acetazolamide) formulations. *Mannitol* - **Mannitol** is an osmotic diuretic used for acute, severe elevations in **IOP**. - It rapidly reduces **IOP** by drawing fluid out of the vitreous and is safe to use in uveitis with elevated pressure. - Its use is typically for short-term, urgent IOP control. *Beta-blockers* - **Beta-blockers** (timolol, betaxolol) reduce **IOP** by decreasing **aqueous humor production**. - They are safe and commonly used to manage **elevated IOP** in uveitic patients. - They do not exacerbate inflammation and are first-line agents for IOP control.
Question 9: Which enzyme is primarily inhibited by the drug prednisolone, leading to its anti-inflammatory effects?
- A. Lipoxygenase
- B. Phosphodiesterase
- C. Phospholipase A2 (Correct Answer)
- D. Cyclooxygenase
Explanation: ***Phospholipase A2*** - Prednisolone, a corticosteroid, primarily exerts its anti-inflammatory effects by inhibiting **phospholipase A2**. - Inhibition of **phospholipase A2** prevents the release of **arachidonic acid** from cell membrane phospholipids, thereby blocking the synthesis of all downstream inflammatory mediators. *Cyclo oxygenase* - **Cyclooxygenase (COX)** enzymes are responsible for converting arachidonic acid into **prostaglandins, prostacyclins**, and **thromboxanes**. - While COX is involved in inflammation, it is primarily inhibited by **NSAIDs**, not directly by prednisolone as its initial target. *Lipoxygenase* - **Lipoxygenase (LOX)** enzymes metabolize arachidonic acid into **leukotrienes**, other potent inflammatory mediators. - While leukotrienes contribute to inflammation, prednisolone's primary mechanism of action is upstream of both COX and LOX pathways, rather than direct LOX inhibition. *Phosphodiesterase* - **Phosphodiesterases (PDEs)** are a diverse group of enzymes that break down cyclic nucleotides (cAMP and cGMP). - PDE inhibitors are used for conditions like asthma and erectile dysfunction, and their inhibition is not the primary mechanism of action for the anti-inflammatory effects of prednisolone.
Question 10: Which of the following drugs possesses similar cycloplegic action and is a more potent mydriatic than atropine?
- A. Hyoscine (Correct Answer)
- B. Tropicamide
- C. Homatropine
- D. All of the above
Explanation: **Explanation:** The correct answer is **Hyoscine (Scopolamine)**. **Why Hyoscine is the correct answer:** Hyoscine is a belladonna alkaloid that acts as a competitive antagonist at muscarinic receptors. In terms of ocular potency, it is significantly more potent than atropine on a weight-for-weight basis. While it produces a **similar degree of cycloplegia** (paralysis of the ciliary muscle), it is a **more potent mydriatic** (pupillary dilator) than atropine. Its duration of action (3–7 days) is shorter than that of atropine (7–10 days), making it a useful alternative when a potent but slightly shorter-acting cycloplegic is required. **Analysis of Incorrect Options:** * **Tropicamide:** This is the shortest-acting mydriatic (duration 4–6 hours). While it is excellent for fundus examination, its cycloplegic action is much weaker and shorter than atropine. * **Homatropine:** A semi-synthetic derivative that is 10 times less potent than atropine. It has a shorter duration of action (1–3 days) and is primarily used in the treatment of anterior uveitis to prevent synechiae without the prolonged blurriness of atropine. **High-Yield Clinical Pearls for NEET-PG:** * **Potency Order:** Hyoscine > Atropine > Homatropine. * **Duration of Action (Cycloplegia):** Atropine (7–10 days) > Hyoscine (3–7 days) > Homatropine (1–3 days) > Cyclopentolate (24 hours) > Tropicamide (6 hours). * **Drug of Choice:** Atropine is the drug of choice for refraction in children <5 years (due to strong accommodation), while Homatropine/Cyclopentolate is preferred for older children. * **Side Effect:** Systemic absorption of atropine in children can lead to "Atropine flushing," fever, and tachycardia.
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