Eyeworld

EW FEATURE 46 Glaucoma medical treatment • November 2015 by Lauren Lipuma EyeWorld Contributing Writer AT A GLANCE • Prostaglandin analogs are the go-to first-line treatment for most physicians. • There is no consensus on second- or third-line treatments, but many physicians choose beta blockers if a patient is unresponsive to prostaglandins. • Branded and generic drops each have advantages and drawbacks; with new pricing schemes, physicians cannot always assume that the generic version of a drug will be the least expensive. "I think fixed combination medications have been a tremen- dous advance in our ability to care for glaucoma patients and improve compliance with medications while minimizing the patient's drop and bottle burden," he said. If the combination drop lowers the IOP well beyond the target pressure, he will sometimes stop the PGA in the hopes of controlling IOP with just one bottle. "I'm big on compliance and adherence, so if the patient is al- ready on a drop, I might go for SLT [selective laser trabeculoplasty] as the next step," said Parag Parekh, MD, DuBois, Pa. "If they don't want SLT, I will go for timolol because I think it's convenient, it's a good medication, and it's inexpensive. If the timolol isn't working enough or if I think they need a big drop in pressure, often I'll go for one of the combo meds, either Simbrinza [brinzolamide/brimonidine, Alcon, Fort Worth, Texas], Combigan, or generic Cosopt. It just depends on how much of a pressure drop I think they need." Branded versus generic medications The branded versus generic de- bate adds a layer of complexity to selecting the right medication for each patient. If a prescription is not affordable, compliance quickly becomes an issue. "Finances and insurance cover- age obviously have a large impact on which medications a patient uses," Dr. Grover said. "In order to provide quality glaucoma care, the physi- cian must understand the financial implications of the recommended treatment plan." PGAs are effective with once-daily dosing, well-tolerated in the eye, and reasonably priced. The cosmetic changes associated with PGAs are more noticeable when the drops are used only in one eye, so for unilater- al glaucoma, Davinder Grover, MD, MPH, Glaucoma Associates of Texas, Dallas, will start with a beta blocker. "In cases where a unilateral beta blocker does not work or is not tolerated, I will occasionally have the patient use a PGA in the fellow eye once a week to minimize the unilateral cosmetic sequelae," Dr. Grover said. Although most physicians choose PGAs as a first-line treat- ment, they don't often agree on second- and third-line treatments. Dana Wallace, MD, Thomas Eye Group, Sandy Springs, Ga., chooses beta blockers as a second-line treat- ment for efficacy and dosing, but will switch to carbonic anhydrase inhibitors or alpha-agonists for patients who have cardiac or respiratory conditions. "I find that when I am moving into second- and third-line medi- cations, my choice becomes very dependent on medical comorbidities and tolerance of medication side ef- fects," Dr. Wallace said. "I tailor my choice based on the patient." Dr. Grover also turns to beta blockers if the patient's glaucoma is not responding to a PGA. Beta block- ers are well-tolerated, have minimal side effects, and have a long history of being safe and effective, he said. If a patient has advanced glaucoma and needs a quick drop in pressure, Dr. Wallace will skip the beta blocker and go straight to a combination drop. "I use combination drops as often as possible once a patient is on more than two medications to try to improve compliance and minimize side effects from preservatives," she said. For Dr. Grover, if a patient is not controlled on a PGA and a beta blocker, he will move to a fixed com- bination drop—either dorzolamide/ timolol (Cosopt, Merck, Kenilworth, N.J.) or brimonidine/timolol (Combigan, Allergan, Dublin, Ireland). In these cases, he will stop the beta blocker and have the patient take the fixed combination drop twice daily. Experts discuss their go-to medical treatments, benefits of branded versus generic drops, and the role of laser trabeculoplasty M edical therapy for glau- coma is, in a way, more art than science. In ad- dition to determining which patients need to be treated and how, physicians have to analyze changes in IOP and visual field loss to assess how fast the disease is progressing and when it's time to move on to the next treatment—changes that are often subtle and different from patient to patient. In addition to those challeng- es, medical treatments options have expanded greatly in recent years—and will continue to expand as companies develop sustained delivery devices and drugs with new molecular targets. It's better to have more options, but there's no defin- itive guide for determining which medication to use for which patient. Here, three experts share their treat- ment strategies for newly diagnosed glaucoma and weigh in on the issues of branded versus generic drops, combination drops, and the role of laser trabeculoplasty as a first-line treatment. Prostaglandins: The first line of treatment Most glaucoma physicians agree that prostaglandin analogs (PGAs) are their go-to first-line treatment for newly diagnosed glaucoma. Navigating through the sea of glaucoma medications Prices for generic medications have gone up over the past several years, and physicians can no longer assume that the generic option is always the least expensive. "I encourage my patients to shop around with regard to their medications and to find a phar- macy that provides them with the most reasonable cost," Dr. Grover continued. "I will sometimes send the patient out with a prescription for latanoprost [Xalatan, Pfizer, New York], bimatoprost [Lumigan, Allergan], and travoprost [Travatan, Alcon] and tell them to purchase the one that is least expensive." Dr. Wallace chooses a brand or generic drop based on what is covered by the patient's insurance— with certain exceptions. "If a patient has an inadequate response to a generic prostaglandin, I will usually try a brand prosta- glandin first before adding a second drop," she said. "If there is a signif- icant improvement in intraocular pressure with this switch, this is a situation where it is preferable to be on a brand medication if it spares the patient from having to use an additional medication. Also, there are higher rates of allergy with generic alpha-agonists, so I favor the brand for this category of medications." Although branded and generic medications have the same active ingredient, the inactive ingredients may differ, and patients can have an adverse reaction to either compo- nent. But it's important to remember that no decision is ever final—you can always switch from a generic to a brand-name product or vice versa, Dr. Parekh said. "In medical management of glaucoma, there's so much follow-up

• Cover
• _GoBack
• _GoBack (1)