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20 EW NEWS & OPINION April 2013 Corralling continued from page 18 going to use a steroid, you might want to start with one of the less potent agents, which also have fewer side effects, for example FML [fluorometholone ophthalmic suspension 0.1%, Allergan] or Alrex [loteprednol etabonate 0.2%, Bausch + Lomb], which is the lower concentration of loteprednol. Lotemax [Bausch + Lomb] is the 0.5% concentration." Henry D. Perry, MD, associate professor, Hofstra University School of Medicine, Rockville, N.Y., likewise initially steers his mild allergic conjunctivitis patients to non-preserved tears. If that's not enough, he moves to combination agents. "I like to use the combined agents in terms of mast cell stabilization and in terms of eosinophil suppressors," Dr. Perry said. "I oftentimes will start with either Lastacaft or Pataday because they're both once daily." For slightly more significant cases he will move to Bepreve. "I think that even though Lastacaft and Pataday are once daily drops, Bepreve twice a day seems to be more effective in terms of duration," he said. If this is not sufficient, Dr. Perry then tries topical steroids. "Once I begin to see signs of allergy like some thickening of the conjunctiva, redness, or changes in the cornea, then I begin to think of more active agents such as Alrex or other mild steroids," he said. These have very low incidence of complications, he finds. For patients who need something slightly stronger, he will move to a steroid like Lotemax. "I think that Lotemax is stronger than Alrex, but I also think that it is on the low end of corticosteroid-induced complication risk," he said. He does not consider more substantive systemic approaches such as immunosuppressive treatment unless the cases are very severe. "To me systemic medications are implied when patients begin to have visual loss or permanent structural changes," Dr. Perry said. In some cases, if the patient has dry eye in association with allergic conjunctivitis, Dr. Perry uses Restasis (cyclosporine ophthalmic emulsion, Allergan). "Restasis has a mast cell stabilizing effect associated with it," he said. "It is also effective in terms of stabilizing the ocular surface, increasing the tear flow, and decreasing the overall inflammation of the eye as time goes by." He usually uses this in conjunction with Lotemax in the initial month of Restasis therapy. Leonard Bielory, MD, principal investigator for the U.S. Environmental Protection Agency on climate change and allergic airway disease, Rutgers University, and attending, Robert Wood Johnson University Hospital, New Brunswick, N.J., finds that many of the patients he sees have been on other therapies before. In his experience, simple antihistamines are the ones often prescribed by primary care doctors. "If they're on oral antihistamines and they're still having symptoms, I do consider taking them off, especially when they're on the first generation oral antihistamine agents such as diphenhydramine and other strong agents that are first generation, which have a high anticholinergic effect," Dr. Bielory said. For many seasonal allergic patients, Dr. Bielory considers using the combination mast cell stabilizing antihistamine agents. He finds that most patients have already been on olopatadine so he moves them to either bepotastine or alcaftadine. He recommends starting these about one week before the patient's season begins. "[The patient] should monitor the pollen counts," Dr. Bielory said. For those in the New York, New Jersey, eastern Pennsylvania, and Connecticut areas, he recommends going to the website nynjpollen.com or using an iTunes app called iPollenCount. "You can download it to you iPad and it lets you graph your symptoms," he said. This can then be emailed to the doctor to evaluate. In terms of ocular steroids, Dr. Bielory uses a burst treatment approach. He will initially put patients on them for up to 10 days using a loteprednol-type of preparation. "When they start approaching two weeks I [tell them] I need to get a baseline ocular exam to monitor the pressure and the baseline opacities of the lens," he said. Rarely does he have any problems with this except in atopic or vernal cases. If patients' track records show that they are getting progressively worse he will consider immunotherapy with shots to improve tolerance. Afterward, patients may withstand 1,000 times more pollen allergens than they did before, he noted. An abstract presented at the American Academy of Allergy, Asthma & Immunology meeting in February, and a more detailed abstract that has been accepted to the Association for Research in Vision and Ophthalmology meeting in May, reported that immunotherapy ("allergy shots") was underutilized by eyecare specialists.1,2 Going forward there are some new approaches being tried. Among other things, Dr. Bielory pointed out that there is sublingual immunotherapy that has been done in Europe, for which a recent Cochrane Review showed a positive trend on the ocular domain. There is also research centering on SEGRAs (selective glucocorticoid receptor antagonists), with a new mapracorat (Bausch + Lomb) under phase 3 investigation. "You can use it like a steroid but without the metabolic side effects," Dr. Bielory said. Dr. Perry concurs. "It has a better safety profile in terms of potentiation of infection, cataractogenesis, and ocular hypertension," Dr. Perry said. "I think that is the pathway of the future." EW Editors' note: Dr. Bielory has financial interests with Allergan, Bausch + Lomb, GlaxoSmithKline (Middlesex, U.K.), Merck (Whitehouse Station, N.J.), and Sanofi (Bridgewater, N.J.). Dr. Perry has financial interests with Alcon, Allergan, and Bausch + Lomb. Dr. de Luise has no financial interests related to this article.