Eyeworld

EW GLAUCOMA 78 October 2016 by Michelle Dalton EyeWorld Contributing Writer Radcliffe said Aerie's drug "potential- ly could be very disruptive because we might be switching patients off their current prostaglandin analogue onto this new fixed combination." The combination netarsudil/lat- anoprost story is equally interesting, Dr. Robin said. Any new glaucoma medication needs to be as safe as a prostaglandin, but work better, and only needs to be administered once daily, he said. The mindset among glaucoma specialists is also starting to change, he said. "I was always taught to start with something that is a single- action drug, and if that doesn't produce the IOP reductions needed, we'd switch drugs. But today, people jump right into combination drugs. If the combination netarsudil/lat- anoprost doesn't have much more hypermedia than bimatoprost and has more IOP-lowering than a prostaglandin, it's going to be a blockbuster drug that addresses a true unmet need," Dr. Robin said. If the FDA approves both netarsudil and the fixed combina- tion, Dr. Radcliffe said, "We'll have thousands of new potential com- binations, which means thousands of new opportunities to benefit our patients and to help find a medical regimen that fits their needs or is tai- lored to the particular needs of each patient." Radcliffe said. "There's a bit more potential there because the market is saturated with prostaglandin analogues, and a truly new and unique class of medications hasn't been introduced in a very long time." Dr. Vold said the fixed combi- nation of netarsudil and latanoprost may "be the most potent drug we've ever had in one bottle." That noted, entry to the market is still challenging—generic medications cost a fraction of the name brand, and cost does factor into treatment decisions, he said. Incremental im- provements in IOP reductions may not be enough to warrant physicians changing their prescribing patterns. Netarsudil monotherapy may have a unique advantage in people with lower pressures and/or normal tension glaucoma, Dr. Robin said. "That's where I see its real place being," he said. "Its use in addition to a prostaglandin will provide some bang for the buck, so to speak. That's where the combination of ne- tarsudil and latanoprost may end up being a first-line drug." For patients concerned about iris color changes or lid changes, or who are older with cardiovascular or pulmonary comor- bidities, its use as monotherapy may be advantageous, Dr. Robin said. The U.S. market has been with- out a fixed combination drug that includes a prostaglandin, and Dr. open-angle glaucoma. That com- pound is based on latanoprost. "We're now using trabecu- lar outflow as a way of lowering pressure. Again, all those concepts of nurturing the outflow pathway, restoring the outflow pathway, using or enhancing physiologic outflow apply, and this may be appealing," said Nathan Radcliffe, MD, assis- tant professor of ophthalmology, Weill Cornell Medical College, New York. Netarsudil "will become a very interesting drug in that it will probably be a first-line drug for people with normal tension glauco- ma," said Alan L. Robin, MD, pro- fessor of ophthalmology, University of Maryland; professor of ophthal- mology, University of Michigan; and associate professor of ophthalmolo- gy and international health, Johns Hopkins University, Baltimore. "The current medications we have seem to work better in people with higher levels of intraocular pressure (IOP), but that may not be the case here." Netarsudil This compound is the first to lower episcleral venous pressure, which is "what makes this a special drug," Dr. Vold said. Because this drug is consid- ered a "pure outflow agent," it will make "a natural complement to the other drugs we're already using," Dr. Leading experts offer their opinions on some of the compounds now in clinical trials T opical pharmacologic treat- ments for glaucoma have not varied drastically in the past few decades, but that may be about to change. Traditionally, medications reduce aqueous production or improve aqueous outflow, increase uveoscle- ral outflow, or affect the episcleral venous pressure. "We now have the potential to have one product that will cover all four mechanisms of action. There's the potential of really making an im- pact in the space," said Steven Vold, MD, founder and chief executive officer, Vold Vision, Fayetteville, Arkansas. Aerie Pharmaceuticals (Waltham, Massachusetts) is about to file netarsudil, a Rho-kinase in- hibitor, for the treatment of primary open-angle glaucoma, and is in late- stage development for its combina- tion netarsudil and latanoprost; data on that drug should be available later this year, according to compa- ny sources. Bausch + Lomb (Bridgewater, New Jersey) has filed latanoprostene bunod for the treatment of primary New glaucoma treatments in development been "very mild," with no cases with cystoid macular edema that could occur with traditional transscleral cyclophotocoagulation. Some patients have developed dry eye after the treatment so Dr. Radcliffe is cautious using the laser in patients who have had a corneal transplant or patients with a bad ocular surface. Instances of inflam- mation and iritis are usually treat- able with steroids, and mydriasis can occur, particularly if the laser treatment is delivered to the 3 and 9 o'clock positions. Complications seen by Dr. Tanaka include inflammation that usually subsides in a few weeks. "Occasionally, the inflamma- tory reaction can be severe with a fibrinous reaction in the anterior chamber," Dr. Tanaka said. Serious complications in pa- tients younger than 60 have in- cluded postop mydriasis and loss of accommodation. MicroPulse laser will likely fur- ther contribute to the general trend of glaucoma treatment including less trabeculectomies, more tubes, and more microinvasive glaucoma surgery. Dr. Radcliffe said the treatment has allowed better care for people with reduced vision and an option for those who have decided that they will not have a trabeculectomy or tube placement. Additionally, it has provided an option for patients who have had silicone oil placed or heavy retinal surgery. "Those are fantastic candidates and they are getting better care now because we have this option," Dr. Radcliffe said. EW Editors' note: Dr. Radcliffe has finan- cial interests with Iridex and New World Medical (Rancho Cucamonga, California). Dr. Tanaka has finan- cial interests with Alcon (Fort Worth, Texas), Allergan (Dublin), Merck (Whitehouse Station, New Jersey), Ellex (Adelaide, Australia), and Glaukos (Laguna Hills, California). Contact information Radcliffe: drradcliffe@gmail.com Tanaka: ghtanakamd@gmail.com MicroPulse continued from page 77

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