Since then? Not so much—a few
me-too drugs that offered little over
the first-in-class prototypes and a
handful of fixed combinations
combining existing drugs with
predictable efficacy and safety
profiles. But no innovation, and
certainly no new paradigm shifts.
Nearly two decades later, we
are overdue for the next round of
innovation in IOP-lowering therapy.
There are a few interesting com-
pounds in development, but none
are likely to materially change the
therapeutic landscape. Why? Be-
cause prostaglandins work too well,
are too safe, and are too convenient
with once-daily dosing. The bar has
been set extraordinarily high—and
there may never come another drug
that can beat the prostaglandin
performance profile.
Thus, it is perhaps not surpris-
ing that the best hopes for novel
drug development in the near future
are either augmentations of the
Prostaglandins have
set the bar high for new
innovations in glaucoma
therapy because of
excellent efficacy
I
n 1978, timolol maleate was
first approved by the U.S. Food
and Drug Administration (FDA)
and forever altered the glau-
coma therapeutic landscape.
Timolol shifted the paradigm from
pilocarpine, epinephrine and oral
acetazolamide, bringing glauco-
ma treatment from the dark ages
into the light. Nearly two decades
would pass before the next series of
glaucoma drug innovations, starting
with the approval of the first topical
carbonic anhydrase inhibitor
(dorzolamide) in 1994 and both
the first prostaglandin (latanoprost)
and the first alpha-2 adrenergic ag-
onist for chronic use (brimonidine)
in 1996. The paradigm shifted again,
and timolol—once the shining
star—became old news.
by Tony Realini, MD, MPH
Glaucoma drug innovation
August 2014
continued on page 54
