Eyeworld

by Nathan Radcliffe, MD Next generation glaucoma therapies and baselines for success F rom the moment we de- cide a patient needs to be treated and we write that first prescription, there are numerous incremen- tal steps where something can go wrong: the patient loses the prescription, or the patient's insur- ance does not cover the prescribed medication and the pharmacist opts to fill the prescription with a generic alternative. Then there's the potential and very real possi- bility the patient will be unable to successfully apply the drop. The data is grim: Only 10% of patients will have 1 year without a refill gap. 1 Overcoming compliance issues The published literature is full of evidence of non-compliance, 2–5 but we've yet to agree on a universal description about how many drops over what course of time defines "non-compliance." Once patients do begin using the medication, however, only 39% of attempted eye drop placement hits the eye, with an average of 1.5 drops delivered per attempt. 6 So their drops are going to run out early. In clinical trials, about 16.5% of patients will have an adverse event and 28% will discontinue therapy. 7 Further, almost 70% of patients who have problems administering eye drops would not tell their doctors, even if directly asked. 8 It's clear that as clinicians, patient compliance and successful use of topical medication is a dif- ficult hurdle. However, tailoring a dosing regimen around a patient's regular schedule can help—one re- view article found a 79% compli- ance rate with QD dosing vs. 51% compliance rate with QID dosing. 9 In my opinion, this is the primary argument for opting to use a pow- erful prostaglandin analog as your first-line therapy, which may be able to prevent a second adjunc- tive therapy. Patient example Simply put, patients who do not adhere to their treatment regimen have worse visual fields and worse vision compared to those who do comply. Figure 1 illustrates the case of a young monocular man who had early glaucoma that required 4 topical agents for pressure control. His fellow eye was blind and pain- ful, and he had been prescribed prednisolone and atropine in that eye. One day, he simply switched the drops. Unfortunately, that was also during a 6-month interval where he did not come in for a check-up. He not only stopped his glaucoma medications in his only seeing eye, he also started a topical steroid that induced a steroid-related glaucoma. When he returned for follow-up, he had advanced glaucoma damage in his only seeing eye with an intraoc- ular pressure of 48 mm Hg. All of this occurred in 6 months, simply because he became confused about his eye drop regimen. Nathan Radcliffe, MD continued on page 6 When the patient did return, his optic nerve had changed dra- matically, from a 0.4 to 0.9. Imag- ing showed dramatic retinal nerve fiber layer loss (see Figure 2). Improving compliance Despite these compliance issues, topical medication remains the first-line therapy for many of our patients. Prostaglandin analogs remain our first-line therapy, but we are fortunate to have several different molecules. Generic latanoprost may improve access to patients who have issues with self-pay, or patients who are actually uninsured. Bimato- prost has been reformulated in a lower concentration and altered preservative levels. In one study, patients who were switched from generic latanoprost to bimatoprost 0.01% experienced significant IOP lowering (17–19.9%, or about 4 mm Hg). 10 It's unclear if there were consistency issues with the generic latanoprost that could explain the huge improvement. Large cohort studies have shown 40% of patients need at Figure 1. Monocular patient well controlled on drops (left) and 6 months after forgetting to take them (right) Forgot drops for 6 months Patient who was well controlled on drops Figure 2. Imaging shows clear disease progression Innovating advanced treatments to increase compliance and improve outcomes for glaucoma patients 4

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