Eyeworld

75 EW GLAUCOMA November 2016 you add another drop and you're basically washing out the first drop," he said. Fixed combination medica- tions can eliminate this effect. Dr. Salim pointed out that it can be less costly for patients to be on a combination agent. "They pay one copay instead of two," she said. However, the downside can be that branded combination med- ications may not be covered by patients' insurance plans. "That's a very frustrating aspect for me as a physician because I want to simplify the regimen for my patients, but they get a lot of pushback from their insurance companies to stay on mul- tiple generic medications," she said. Dorzolamide/timolol has become Dr. Salim's go-to combina- tion agent because it is generic and patients have easier access to it. She tends to shy away from Combigan because of allergy issues that can occur at any time after initiation of medication. While this only occurs in about 5% of patients, when it happens, it is very uncomfortable for the patient and adversely affects adherence, she noted. There are also tolerability issues to consider. "By using a fixed com- bination, you're putting one drop in the eye instead of multiple drops and preservatives," Dr. Patrianakos said. Then there is the issue of side effects, which can likewise be di- minished with combination agents. "There have been studies that show combining drops into one bottle decreases the adverse events caused by the individual components of each bottle," Dr. Patrianakos said. "There was a study that showed that combining a beta blocker with an alpha agonist leads to less conjunc- tival hyperemia than with the alpha agonist by itself because the beta blocker component blocked cell shrinkage." 1 So in terms of the effect of combining multiple medications, physicians may decrease the adverse effects of one of those medications with the other, he explained. Another reason Dr. Patrianakos advocates putting a patient on a combination agent is to help reduce the "washout effect." This can occur "when you put a drop in the eye and then within a couple of seconds Dr. Patrianakos gears his choice of combination agent to whatever the patient's comorbidity may be. "I wouldn't put patients on a beta blocker if they had a decreased heart rate or if they had problems breathing; I would pick another combination medicine to use," he said. For such a patient, Simbrinza, which is beta blocker free, would be his choice. Overall, Dr. Patrianakos would like to see more combination agents available in the U.S. In Europe, there are prostaglandin analogues com- bined with other medicines, which are not available here. "For the U.S. FDA to approve something, it has to show greater efficacy with a combi- nation medicine than the individ- ual components dosed at the same frequency, and we haven't been able to come up with it," he said. "But it would be nice to have a combina- tion medicine that's once a day—so combined with a prostaglandin." Dr. Patrianakos pointed out that there is promising work being done with rho-kinase inhibitors and prostaglandin analogues, which may someday clear this bar. "I think it would be nice to get a fixed-combi- nation medicine that is once-a-day dosing and where the medications work in different mechanisms or outflow systems," he said. If one medication works by increasing aqueous humor outflow and the other by decreasing aqueous humor production, he thinks that would help quite a bit. EW Reference 1. Sherwood MB, et al. Twice-daily 0.2% brimonidine-0.5% timolol fixed-combination therapy vs monotherapy with timolol or bri- monidine in patients with glaucoma or ocular hypertension: a 12-month randomized trial. Arch Ophthalmol. 2006;124:1230–1238. Editors' note: Drs. Patrianakos and Salim have no financial interests related to their comments. Contact information Patrianakos: tpatrianakos@cookcountyhhs.org Salim: ssalim@mcw.edu Follicular conjunctivitis due to brimonidine Source: Sarwat Salim, MD, FACS Iris heterochromia with darker iris and hypertrichosis in the left eye due to monocular treatment with latanoprost Source: Sarwat Salim, MD, FACS

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