Is it necessary to wear an ankle brace 24 hours a day for an ankle sprain, and is Dymista (azelastine/fluticasone) nasal spray contraindicated in patients with glaucoma?

Management of Ankle Sprain and Safety of Dymista in Glaucoma Patients

Ankle Sprain Management

For ankle sprains, a functional approach with a semi-rigid ankle brace worn during waking hours (not 24 hours/day) for 3-6 weeks is recommended, rather than continuous bracing or elastic bandages like Tubigrip. 1

Optimal Bracing Protocol

• Semi-rigid or lace-up ankle braces with straps are more effective than elastic bandages (like Tubigrip) or tape for treating ankle sprains 1, 2
• Bracing should be used during waking hours when weight-bearing, not continuously for 24 hours 1
• Duration of brace use depends on injury severity:
  • For mild-moderate sprains: 2-4 weeks 1
  • For severe sprains or partial/total ligament rupture: 3-6 weeks 1

Treatment Timeline

• First 3-5 days: Rest, ice, compression, elevation with early weight bearing as tolerated 1
• After 48-72 hours: Begin active exercises while continuing to use the brace during weight-bearing activities 1
• Return to work timeline:
  • Sedentary work: 2-4 weeks (depending on severity) 1
  • Physically demanding work: 6-8 weeks for severe sprains 1

Why Semi-rigid Braces Are Superior

• Semi-rigid braces lead to faster functional recovery compared to elastic bandages (Tubigrip) 1, 3
• Studies show significantly higher functional scores at both 10 days and one month with semi-rigid braces versus elastic bandages 3
• Semi-rigid braces are the most cost-effective option compared to taping 1
• Bracing is superior to taping and neuromuscular training for preventing recurrent sprains 1, 4

Common Pitfalls to Avoid

• Avoid continuous 24-hour bracing as this may lead to muscle weakness 1, 5
• Don't rely solely on elastic bandages like Tubigrip, as they provide insufficient support 1
• Don't immobilize the ankle completely, as functional treatment leads to faster recovery 1
• Compression bandages alone have insufficient evidence for reducing swelling or pain 1

Dymista and Glaucoma

Dymista nasal spray (azelastine/fluticasone) should be used with caution in glaucoma patients due to the potential risk of increased intraocular pressure from the corticosteroid component. 6

Safety Considerations

• The FDA label specifically warns that nasal corticosteroids may result in the development of glaucoma and/or cataracts 6
• Close monitoring is warranted in patients with a history of increased intraocular pressure, glaucoma, and/or cataracts 6
• In a 12-month controlled study, one patient using Dymista developed increased intraocular pressure at month 6 6

Monitoring Recommendations

• Regular monitoring of intraocular pressure and slit lamp examinations are recommended for glaucoma patients using Dymista 6
• If changes in vision occur or intraocular pressure increases, consider discontinuing Dymista 6
• Unlike some other nasal decongestants (e.g., oxymetazoline) which may actually lower intraocular pressure 7, the corticosteroid component in Dymista poses potential risks for glaucoma patients

Alternative Considerations

• If the patient has well-controlled glaucoma and requires treatment for allergic rhinitis, the benefits of Dymista may outweigh the risks, but careful monitoring is essential 6
• Consider consulting with the patient's ophthalmologist before initiating Dymista therapy in glaucoma patients 6