Eyeworld

EW GLAUCOMA 106 February 2011 March 2011 tween Voltaren (diclofenac, Novartis, Basel, Switzerland) and its generic versions, with increased pa- tient complaints as well, Dr. Cantor said. He tries to keep his patients on branded versions, "but if the only thing they can get is the generic, the burden is to show it is as effective as its branded counterpart. I suggest counseling patients that when they begin medical therapy with a generic, they may not respond as well as they did on the branded ver- sion or their responses may vary de- pending on which generic they've been given." The availability of generic prostaglandins may be "the biggest glaucoma story of 2011, and physi- cians will be eager to quickly find out how well these generics are working relative to branded medica- tions as well as to other generics," Dr. Singh said. "Some differences will be science-based and others will be anecdotal in nature. IOP is a very difficult parameter to assess due to the significant fluctuation over the diurnal and nocturnal periods. When you switch patients to new medications or generics, it is often difficult to determine whether the switch or the fluctuation in IOP is the primary reason for a change in IOP relative to the previous visit. Ocular tolerability, in contrast, is easier to assess as patients will com- monly bring side effects to the physician's attention." Aside from potential tolerability issues with a generic version, "it's becoming a money issue, as is com- pliance," Dr. Noecker said. Different formulations One way pharmaceutical companies have avoided the immediate hit to their bottom line when most name brands have generic competition is by introducing newer formulations of the current branded product, which is what Allergan (Irvine, Calif.) has done with Lumigan (bimatoprost). Lumigan 0.01% "has allowed us to decrease the amount of hyperemia we see in patients but keeps the same efficacy as the earlier iterations," said Thomas K. Mundorf, M.D., Mundorf Eye Cen- ter, Charlotte, N.C. Clinicians continue to incorpo- rate different treatments into their paradigms, Dr. Samuelson said, which has increased since the intro- duction of the prostaglandin class of drugs as well as the introduction of newer surgical treatments. "Lumigan 0.01% is likely to be used and widely adopted from Lumigan 0.03%," Dr. Samuelson said. "The lower dose seems as effi- cacious as the 0.03% version and has a better tolerability profile." Dr. Cantor agreed, saying Lumi- gan "has been a good medication for many years, and a great addition to our treatment regimen is the 0.01% version. There are fewer side effects being reported—it is an improved and approved medication." "Prostaglandins are still the pri- mary medical therapy of choice to treat glaucoma," Dr. Singh said. "Topical medication will remain the first glaucoma treatment choice, and prostaglandins will remain the num- ber one class of drugs for first-line use in the coming years. With all of the talk about noncompliance and other limitations of medical therapy, the reality is that most patients who are diagnosed early and begun on medical therapy, even with all of its limitations, do quite well," Dr. Singh said. Dr. Mundorf said research in Phase II trials is now investigating new classes of drugs for the treat- ment of ocular hypertension and/or elevated IOP, but "it is too early to determine how successful they're going to be or if they could work with a prostaglandin." Managing patient expectations There remains a fine line between when a specialist should add an- other medication to the patient's regime and when surgical therapy should be entertained. "It's really patient-dependent these days," Dr. Noecker said. "Pa- tients know their options, and if they're on every drug we can pre- scribe, they appreciate being off medications. Surgery allows us to potentially reduce medications and maybe end up not having to put a patient back on them at all. Part of that, however, is choosing the right patient to recommend a move away from medical management." Because he expects to "see some big problems with some of the newer generics that are going to be introduced this year, it's kind of changing the game," Dr. Noecker said. With an "evolution" toward more procedures rather than intro- ducing patients to more generic medications, "I'm more likely to in- tervene earlier." People will be pushed into ac- cepting generic medications because of their insurance tiers, but "unlike some products, you can't just push some of these glaucoma compounds together," he said. Variability in re- sponse and bioavailability are his two biggest concerns with the prostaglandin class of medications. For Dr. Mundorf, as long as a pa- tient's level of vision remains steady or has minimal change that might be associated with disease progres- sion rather than incompatibility with a medication, he's likely to keep the status quo and not move a patient to surgical management. "We need to recognize early enough when the increases in IOP start impacting a patient's quality of life," he said. "We will need to con- tinue to act before the IOP changes Introducing the all-new With ONE simple tool customized for YOU — send routine forms, appointment reminders, and personalized education to your patients. We've worked in the social media aspect so you can stay connected with your patients and reach new ones without all the headache. E Y E M AG I N AT I O N S 877.321.5481 | info@eyemaginations.com Take a sneak peek at International Vision Expo East (booth MS1131) or ASCRS (booth 2315). Is your head swimming trying to keep up? 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