Eyeworld

EW NEWS & OPINION 18 April 2015 Pharmaceutical focus by Maxine Lipner EyeWorld Senior Contributing Writer than either a mast cell stabilizer alone or an antihistamine alone." Dr. Lindstrom concurs, explain- ing that these are a natural, given the pathophysiology of allergic conjunctivitis. "We have mast cells and eosinophils in the conjuncti- va and they release histamine and some other cytokines, bradykinin, slow-reacting substance A, and some prostaglandins," Dr. Lindstrom said. "But the primary ideology is eosino- phil and mast cell-releasing hista- mine causing severe itching as the primary symptom." While there are individual drops that are just mast cell stabilizers and those that are just antihistamines, in Dr. Lindstrom's view there is no rea- son not to use a combination agent. Of these the 3 most commonly prescribed are Patanol (olopatadine hydrochloride ophthalmic solution 0.1%, Alcon, Fort Worth, Texas), Pataday (olopatadine hydrochloride ophthalmic solution 0.2%, Alcon), and Bepreve (bepotastine besilate ophthalmic solution 1.5%, Bausch + Lomb, Bridgewater, N.J.), he said. "I personally find these 3 drops to be equivalent in their efficacy," Dr. Lindstrom said. Dr. Holland finds that choosing between these often comes down to patient preference with regard to dosing. Pataday is administered once a day versus twice a day for Patanol and Bepreve. Lastacaft (alcaftadine, Allergan, Irvine, Calif.) also has once-a-day dosing. While Dr. Holland views this as quite effective, it can be a bit more uncomfortable for some patients, in his experience. "I think patients notice a bit more sting with that one than some of the others," Dr. Holland said. "But I think they're all quite effective." He finds that all of these prescrip- tion combination agents perform better than their one non-prescrip- tion counterpart Zaditor (ketotifen fumarate ophthalmic solution, Novartis, Basel, Switzerland). Dr. Lindstrom views Zaditor as quite effective as an over-the- counter agent, but finds that most patients whose allergies are severe enough to seek out an ophthalmol- ogist have already tried this. "Most ophthalmologists choose to write a prescription for a prescription drop if they're treating a patient," Dr. Lindstrom said. Adding in steroids For some patients, however, even a prescription combination agent may not be enough. In such cases, Dr. Holland recommends adding a burst of topical steroid. "Loteprednol is my favorite because of the safety profile," he said. "It doesn't tend to raise IOP like some of the other steroids do, and it is quite effective for patients with allergic conjuncti- vitis." If an allergic conjunctivitis patient is still symptomatic within 1 or 2 weeks, however, Dr. Holland suggests an oral antihistamine be taken together with the other medi- cations here. Dr. Lindstrom also finds that for seasonal allergic patients who have reached the point of significant conjunctival edema, a topical steroid is needed. For this he prefers steroids with fewer side effects such as FML (fluorometholone alcohol 0.1%, Allergan) and Lotemax (loteprednol 0.5%, Bausch + Lomb). "These drugs penetrate the eye less and are less likely to have the secondary side effects of elevated IOP and cataract if people are using them for an extended period of time," Dr. Lindstrom said, adding that many allergy patients might be using such agents year after year. For patients with milder allergy who need a slight boost, Alrex (loteprednol etabonate ophthalmic suspension 0.2%, Bausch + Lomb), which is a lower concentration of loteprednol, might be sufficient, he said. "Alrex is labeled for allergy, and in the clinical trials and in clinical use it has a very good safety profile," Dr. Lindstrom said. He finds this to be a good in-between drop. Howev- er, for more severe cases, he does not consider this. "If you have severe chemosis and your lids are swollen shut, then you've got to use a full strength steroid like loteprednol 0.5%," he said. "But if you're not well managed with an antihistamine mast cell stabilizer and you need something a little stronger, I find Alrex to be a good drug." In Dr. Holland's view, ophthal- mic practitioners do not do enough preventive therapy. "If we know that patients have seasonal allergic con- junctivitis and that May is typically a bad month, we often forget what the allergists do and that's to start therapy prior to the patient becom- ing symptomatic," he said "That's how these medications work best." He tells patients not to wait until they have a full-blown allergic con- junctivitis reaction to begin therapy, pointing out that it takes a lot more medication to shut down a reaction than it does to prevent one from occurring. The fact is that while antihista- mine medication can work quickly, mast cell stabilizers can take a few weeks, Dr. Holland said. "You want Weathering the allergic conjunctivitis storm Understanding the umbrella of treatments F or all too many, April is the time of year when ocular allergies are brewing. Such allergies are common, said Richard L. Lindstrom, MD, adjunct professor emeritus, Universi- ty of Minnesota, Minneapolis. "Roughly 50 to 60 million Americans have allergic conjuncti- vitis, and (of those) 90% are season- al, 5% are perennial, and a small number are atopic or vernal," Dr. Lindstrom said. Whether patients have seasonal allergic conjunctivitis or the year- round cousin, perennial allergic conjunctivitis, itching is one of the overriding symptoms, he said. Typ- ically dry eye patients complain of a gritty foreign body sensation that gets worse later in the day, and those with blepharitis have some itching but more of a burning sensation. For patients with allergic conjunctivitis, the sensation is of itching. "This is often located nasally right over the caruncle, because the caruncle is lymphatic tissue and it's loaded with mast cells that release histamine," he said, explaining that it is the histamine that itches. Edward J. Holland, MD, profes- sor of ophthalmology, University of Cincinnati, finds that in managing allergic conjunctivitis patients, the severity of symptoms comes into play. "There are patients who have mild disease, and they typically can be managed with some of the over- the-counter medications, whether it's an antihistamine or a mast cell stabilizer," Dr. Holland said. "We base our treatment on the symp- toms." Patients with short-term season- al allergic conjunctivitis can get by with over-the-counter topical anti- histamine or mast cell stabilizers, he said. Typically, however, patients who go to see an ophthalmologist have either severe or chronic symp- toms and are looking for another treatment option. Combination treatment "The combination antihistamine/ mast cell stabilizers are the first-line therapy for anyone with significant symptoms," Dr. Holland said. "This class of medication is more effective Allergic cascade Source: Richard L. Lindstrom, MD continued on page 20

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