Eyeworld

EW GLAUCOMA 74 November 2016 by Maxine Lipner EyeWorld Senior Contributing Writer When multiple glaucoma medicines are needed T he need to take multiple medications is a common issue for patients with glaucoma. "Nearly 50% are taking more than one medi- cation to reach their target IOP," said Sarwat Salim, MD, FACS, professor of ophthalmology and chief of the glaucoma service, Medical College of Wisconsin, Milwaukee. Can such patients be better served by the use of combination glaucoma medica- tions with two agents in one bottle? Options include dorzolamide and timolol, brimonidine and timolol (Combigan, Allergan, Dublin), and brinzolamide and brimonidine (Simbrinza, Alcon, Fort Worth, Texas). EyeWorld asked practitioners to take a closer look at this issue. There can be many challenges in dealing with multiple medica- tions. "Glaucoma is a disease that is asymptomatic and it mostly occurs in an elderly population," Dr. Salim said, adding that older patients may have other coexisting systemic dis- eases requiring additional systemic medications. This can further com- plicate things for the patient and ultimately interfere with treatment success. "The more complex the reg- imen, the lower the adherence," Dr. Salim said. Only about one-third of those for whom multiple glaucoma medications are prescribed are fully Forest, Illinois). "Unfortunately, there are many patients who may not reach their target IOP with just one prostaglandin analogue," she noted. However, just because one drug in this category isn't lowering pressure doesn't mean you shouldn't try another before moving on. If the prostaglandin alone is not sufficient, for Dr. Salim it then becomes a question of whether to move on to a single agent from an- other class or to use a combination medication. This will depend some- what on where the patient is on the spectrum of disease, she explained. If the patient has early to moderate disease and needs a second medica- tion, Dr. Salim may add a beta block- er or carbonic anhydrase inhibitor as long as the patient doesn't have any contraindications. "In eyes with advanced glaucoma and inadequate response to the prostaglandin ana- logue, I often go to a combination medication because I don't want to waste time trying one drug at a time," she said. Dr. Salim added that the disadvantage with this approach is that physicians don't know how adherent to their medical regimen, making compliance a key issue for glaucoma specialists. Considering challenges Thomas Patrianakos, MD, chair of ophthalmology, Cook County Health and Hospital System, Chica- go, agreed. "The biggest challenge is adherence to the medications," he said. "There are also some challenges in terms of ocular surface disease and tolerability because of the pre- servatives in the medication." That is, the more medication a patient is on, the greater the chance of ocular surface disease and intolerability to medications, he stressed. Dr. Patrianakos generally prescribes combination medicines as second-line agents. "Usually my first-line agent is a prostaglandin analogue," he said, adding that he then switches to either a single medication like a beta blocker or to a combination medicine. Likewise, Dr. Salim usually begins with a prostaglandin ana- logue, which is the most commonly prescribed class of drugs. "I prefer this class because of its potency, con- venient once-a-day dosing, lack of systemic side effects, and sustained effect over 24 hours," Dr. Salim said. Options in this category include Xalatan (latanoprost, Pfizer, New York), Lumigan (bimatoprost, Aller- gan), Travatan Z (travoprost, Alcon), and Zioptan (tafluprost, Akorn, Lake much pressure reduction is coming from each of the components of the combination drug. The only time she may prescribe a combination agent as primary therapy is when a patient needs significant IOP lowering but is reluc- tant to use a prostaglandin because of its potential ocular side effects, such as change of iris color, growth of lashes, or darkening of the skin around the eyes. Reasons to switch If a patient comes in on two med- ications, both Dr. Salim and Dr. Patrianakos said it is best, if possible, to switch the patient to a combina- tion agent. There are several reasons to do that, Dr. Patrianakos finds. "I think it improves adherence because if you simplify the patient's drug regimen then it will lead to less patient error and increase conve- nience for the patient," he said. "In multiple studies, adherence has been shown to decrease as the number of medicines, bottles, and drops increases." Formidable combinations Having to only administer one drop, in the form of a combination agent, can lead to enhanced compliance. Source: Thomas Patrianakos, MD " I think it improves adherence because if you simplify the patient's drug regimen then it will lead to less patient error and increase convenience for the patient. " –Thomas Patrianakos, MD Pharmaceutical focus

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