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EW GLAUCOMA 70 November 2015 by Maxine Lipner EyeWorld Senior Contributing Writer property," he said, adding that this may run counter to what many practitioners have been taught. "The way many of us were trained, we were taught not to put two medi- cines in an eye if one might work," Dr. Radcliffe said. "You don't want to expose patients to extra molecules and increase their risk of side effects, which is seemingly the most logical reasoning in the world." But in some cases, it turns out that the combined safety profile may not be double the side effects, and there may be some synergy to the way the molecules work, he said. With the aid of fixed combina- tions, practitioners can determine more rapidly whether drugs are going to work for the patient. Dr. Radcliffe cited a November 2002 article that appeared in Ophthal- mology that showed there are many combinations that practitioners could try on any glaucoma patient. However, at some point it becomes a question of whether the patient is actually treatable with medication. With fixed combination therapy, it may be possible to arrive at this conclusion much sooner. "I think that most of us would agree that if you have a patient who is on a pros- taglandin analogue with one of the fixed combination agents, they're almost on maximum therapy," Dr. Radcliffe said. "If you do that in two office visits, then you've treated that patient very efficiently and you can get them to whatever their definitive therapy is going to be." Considering single agents? Still, some think that there is a role for single-dose therapy even with more moderate disease. "Some physicians will do what's called risk stratification where if they have a patient who just needs a little pres- sure lowering but is very close, they will just use a single agent," Dr. Radcliffe said. "Their argument would be, 'It's generic; I can do a once-a-day timolol. If someone is way out of control, I'll add a fixed combination, but if they're close and just need a little more, I'll use a single agent.'" However, there are other phy- sicians who work on the principle that no one is safe from glaucoma and that it's only going to get worse so they don't want to be on the team that underestimates glaucoma. Update on combination drugs A t least one-third of the time, any given patient diagnosed with glaucoma or ocular hypertension will be on more than one medication, according to Nathan M. Radcliffe, MD, clinical professor of ophthalmology, New York Univer- sity Langone Medical Center, New York. Many of these patients end up on fixed-combination medications. EyeWorld is delving into the latest on these medications. In the U.S., there are currently 3 fixed combinations. The first one to market was known by the brand name Cosopt and is a combination of dorzolamide hydrochloride 2% and timolol maleate 0.5%, Dr. Radcliffe noted, adding that this is now a generic drug. The other two medications are Combigan (brimo- nidine 0.2% and timolol 0.5%, Allergan, Dublin) and Simbrinza (brimonidine 0.2% and brinzol- amide 1%, Alcon, Fort Worth, Texas). Considering the benefits The fixed-combination agents can offer patients advantages over taking two different drugs independently, said Parag Parekh, MD, DuBois, Pa. One benefit is convenience. Two different medications must each be dosed several times a day. "If you put two bottles into one, you de- crease the amount of work that pa- tients have to do," Dr. Parekh said. "The other way to think of it is you decrease the number of possibilities for mistakes." This may also result in financial savings for patients. "De- pending on the insurance plan, it might only be one copay as opposed to two," he said, adding that the flip side of that, however, is if the com- bined medication isn't covered by insurance it might be more expen- sive for the combined product than the two individual agents. There can be other more subtle benefits as well. If someone is taking a combined medicine twice a day, he or she is getting lower eye pressure than someone taking a single med- ication twice a day. "You're getting more effect for the same amount of work that you're putting in as a patient," Dr. Parekh said. Dr. Radcliffe pointed out that certain combinations may even have fewer side effects than when the medication is taken alone. "I did a review of the fixed combinations and found that for a medicine that had timolol in the bottle, oftentimes there would be less hyperemia or redness and allergy," Dr. Radcliffe said. Specifically, he found that this was true for latanoprost, bimato- prost, and brimonidine. "Something about the timolol is either quieting for the eye or has some anti-allergy Coupling up glaucoma medications Pharmaceutical focus For eyes with glaucoma, fixed combination agents may decrease the possibility of mistakes with eye drops. Source: Nathan M. Radcliffe, MD

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