AUG 2014

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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EW NEWS & OPINION 16 August 2014 by Maxine Lipner EyeWorld Senior Contributing Writer Future of compliance issues Despite practitioners' best efforts to adjust medications and educate patients, some may never be compliant, Dr. Robin concedes. "I don't believe that most patients, if they're not adherent, will change," he said. Even fear of blindness is not motivation enough for some pa- tients. Part of this is a fatalistic issue, he explained. "Some patients believe that no matter what they do, they're going to go blind," he said. "That's a hard one to counter." Going forward, Dr. Robin thinks new classes of medication that last for months or even a year or drug delivery systems that take compli- ance out of the patient's hands will be the key. Dr. Trattler agreed. One of the things already being tried in cata- ract surgery, he said, is the "drop- less approach." "We're using more intraoperative medications to try and reduce the need for drops before and after surgery," Dr. Trattler said. TriMoxi (Imprimis Pharmaceuticals, San Diego) contains both vanco- mycin and a steroid, and can be ad- ministered during the cataract case. Omeros (Seattle) recently received FDA approval for its intraocular product, which combines a non- steroidal with phenylephrine. This product has been shown to reduce postop discomfort and has the po- tential of helping with inflammation control during the postop period. Ultimately, Dr. Newman-Casey thinks technology will make the dif- ference, and she hopes to see drop bottles equipped with electronic dose counters become the standard on the market. EW Editors' note: Dr. Newman-Casey has no related financial interests. Dr. Robin has financial interests with Aerie Pharmaceuticals (Bedminster, N.J.), Allergan, Merck, OHR Pharmaceutical (New York), and Sucampo Pharma- ceuticals (Bethesda). Dr. Trattler has financial interests with Alcon, Allergan, Bausch + Lomb, and Imprimis. Contact information Newman-Casey: panewman@med.umich.edu Robin: arobin@glaucomaexpert.com Trattler: wtrattler@gmail.com and Ilevro (nepafenac, Alcon, Fort Worth, Texas), both of which are dosed just once a day. For glaucoma he finds that the once-a-day Lumigan (bimatoprost, Allergan, Irvine, Calif.) or Travatan (travo- prost, Alcon) work nicely, and if cost is an issue, generic latanoprost can be used once a day. Also, the comfort of the drop plays an important role, he said. "If the medications burn or irritate the eye, patients are less likely to want to use the drops," he said. Dr. Robin agreed that comfort as well as visible side effects could affect compliance. "If the eye turns red, patients are aware of that," he said. Also, they want drops that do not burn, he said. "For glauco- ma, pilocarpine burns and dorzol- amide burns and a generic fixed combination of dorzolamide and timolol burns because of the PH," Dr. Robin said. Instead, for a car- bonic anhydrase inhibitor, practi- tioners may prescribe something like Azopt (brinzolamide, Alcon) or the combination agent Combigan (dorzolamide/timolol, Merck, White- house Station, N.J.). "There is a cost tradeoff, so it's [ultimately] the patient's decision," Dr. Robin said. "Most physicians don't ask [pa- tients] if the cost of the medication is too much. Most individuals who require medication on a chronic level are usually those who are on multiple medications or may be on fixed incomes." said. "After (cataract) surgery, we're assuming that they're using their drops and if they're improving as we expect, we're not going to press them," he said. "But if they're not getting better then we are more like- ly to ask them if they're being com- pliant with their postop regimen." Enhancing compliance Dr. Trattler views patient education as pivotal in enhancing compliance. "This means explaining to patients why it's important to use their medications so they understand the urgency and the reason to use them," Dr. Trattler said. That education may range from explaining to patients that it is important to use medications to get the best outcomes, to stressing that if they do not, they may be at increased risk for infection and inflammation. "If a patient has glaucoma, this means explaining that if they don't take their medication long term, they can end up with visual field damage and permanent vision loss," Dr. Trattler said. The medication itself may also play a role here. Dr. Trattler thinks the need for less frequent dosing is likely to yield greater compliance. "Once-a-day drops are more likely to be used than twice-a-day drops," he said. With this in mind, Dr. Trattler's go-to nonsteroidal drugs are Prolensa (bromfenac, Bausch + Lomb, Bridgewater, N.J.) Enhancing adherence across subspecialties I t is an issue that cuts across medical specialties: adherence problems. Ophthalmology is no exception, with many ophthal- mologists in different subspe- cialties wrestling with just how to guarantee that prescribed drops find their mark. This is a major issue in glaucoma, said Alan L. Robin, MD, associate professor of ophthalmology and international health, Johns Hopkins Universi- ty, Baltimore; adjunct professor, University of Michigan, Ann Arbor; and clinical professor, University of Maryland. "You can have a drug that works wonderfully, but if a patient doesn't take it or doesn't take it correctly, it has no value—it's just a waste of money," Dr. Robin said. Paula Anne Newman-Casey, MD, assistant professor, University of Michigan, agreed. "We know that at least one-third of glaucoma pa- tients don't take their medications," she said. But one-third is probably a low-ball estimate—she thinks that the true amount is probably closer to about half of all patients. "When you look at other chronic diseases like hypertension, diabetes, high cholesterol, asthma, or HIV, they have very similar rates of people having trouble taking their medications," she said. "We have all these effective treatments but if people don't use them, there's no purpose to them." One of the major stumbling blocks for practitioners may be in ferreting out just who is adherent and who is not. "When you look to the literature to get an idea of the concordance between providers' perceptions of adherence and the patients' adherence as monitored either electronically or through self-report, it is very poor," Dr. Newman-Casey said. "We don't know who our adherent or non- adherent patients are." Likewise, William B. Trattler, MD, Center for Excellence in Eye Care, Miami, believes that practi- tioners are left pretty much in the dark, not just in glaucoma treatment but also in cataract surgery. "We don't know who is being compli- ant unless they admit it to us," he Outwitting noncompliance Pharmaceutical focus Placement of eye drops in a patient Source: William Trattler, MD

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