Eyeworld

71 EW GLAUCOMA November 2015 there is a triple fixed-combination agent known as Krytantek (Labora- torios Sophia, Jalisco, Mexico) that combines brimonidine, timolol and dorzolamide. With patients requiring a variety of fixed combinations for individu- al reasons, the more combinations available, the better, Dr. Radcliffe thinks "The FDA has been a little restrictive, but I think [from a physi- cian's standpoint], we want all of the options on the table," he said. EW Editors' note: Dr. Parekh has financial interests with Alcon, Allergan, and Bausch + Lomb (Bridgewater, N.J.). Dr. Radcliffe has financial interests with Allergan. Contact information Parekh: parag2020@gmail.com Radcliffe: drradcliffe@gmail.com Dr. Radcliffe falls into this camp. "The rationale there is [we should try to] get ahead of the glaucoma," he said, adding that while two agents at the moment might be a bit more than is needed, he would rath- er be ahead of glaucoma than chas- ing after it. Those who are glaucoma specialists who see more severe cases and who do tertiary referrals tend to be more aggressive right off the bat. "Physicians who are blessed to have patients who are doing better have the luxury of adding just one medicine at a time," he said. Dr. Parekh usually starts with a single-dose medication such as the prostaglandins with a drug like Xalatan (latanoprost, Pfizer, New York), Lumigan (bimatoprost, Allergan), or Travatan (travoprost, Alcon). "Those are nice because they're once a day, and they're powerful in how much they bring down the eye pressure," he said. But if the patient has issues with prostaglandins and these are not going to work as the first choice, it becomes a question of whether to use one of the fixed combinations or perhaps just timolol. "The timolol once a day is an attractive regimen. I typically prescribe it every morning and that's all I dose," he said. "But using the combination medications typically has more of an effect, so it's very specific to the situation and how much lower the pressure needs to be." If the patient just needs the pressure down a few points, the practitioner could just add timolol and get the patient's pressure down enough, he explained, adding that each situation is different. Dr. Radcliffe is inclined to use fixed combinations. He tends to favor Combigan because he thinks that patients will remember this name better than the gener- ic combination of dorzolamide hydrochloride and timolol maleate, which he finds also has a sting to it. There have been several head-to- head studies comparing Combigan and Cosopt where Combigan has had an edge in terms of efficacy. "It does have good data for its efficacy added to latanoprost." Meanwhile, he thinks that Simbrinza, which is newer to the market, provides a valuable option for patients who have asthma or who can't tolerate a beta blocker. A couple of new combinations may be coming down the pike. The drug Roclatan (Aerie pharmaceutical, Bedminster, N.J.) combines Rhopres- sa and latanoprost. So far this has completed phase 2B FDA clinical trials, Dr. Radcliffe said, adding that if this is approved, it will be the first fixed combination in America to include a prostaglandin analogue in conjunction with another agent. In addition, currently in Mexico

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