Eyeworld

47 EW FEATURE August 2017 • Steroids roundup Steroid and cataract/ IOP connection One concern surgeons have about steroid use is the risk for an IOP rise/ glaucoma and the risk for cataract formation. "There's no free lunch," Dr. Verdier said. "The better the steroid anti-inflammatory effect, the greater the risk of associated steroid-related increased IOP as well as other con- cerns such as cataract formation." Dr. Perry always keeps in mind the pecking order of steroid potency when making his treatment choice. "Durezol is the strongest we have, but it increases IOP," he said. Ophthalmic surgeons must consider the steroid potency and as- sociated risk of IOP rise (or cataracts) when deciding which to use. "Some newer molecules, loteprednol being one, are more potent than people re- alize and yet they carry a lower risk of steroid response," Dr. Starr said. "Stronger steroids don't increase the number of patients who respond to them, but they do increase the level of IOP rise in that responding group. It's estimated that 10% of patients are IOP responders to ke- tone steroids," Dr. Holland said. For patients with a need for long-term steroid use, Dr. Holland will consider tapering to a slightly less potent but safer steroid. For instance, lotepred- nol is a very effective steroid but has been found to only raise the pres- sure in 1.8% of the population. However, there can be different ways to think about side effects like glaucoma or cataracts. Dr. Sheppard thinks that the cataract concern is lessened because cataracts are so easily treatable. In fact, he's seen treatment backfire because patients didn't receive enough steroids to treat inflammation due to a fear of this occasional side effect. "The biggest problem I see in a referral corneal practice is that patients don't get enough steroids, and the disease is allowed to remain smoldering or undercontrolled," he said. One exception he makes is in children, where the risks from steroid therapy are higher. For this reason, he works closely with pedi- atric rheumatologists and parents of patients to make sure they adhere to strict medication regimens and re- turn to all follow-up appointments. Cost issues With cost an ever-present concern for many patients, one guiding prin- ciple surgeons keep in mind is that a more potent steroid will be used for less time—and that often means less money spent. Although there has been a big push for generic prescriptions over branded ones throughout medicine because of their perceived lower cost, that approach seems to backfire in some markets. "Many generics have increased significantly in price. In many markets, branded Acanthamoeba keratitis in a daily wear soft contact lens patient initially treated with tobramycin/dexamethasone drops for bilateral ocular burning and redness Source: David Verdier, MD difluprednate is cheaper than gener- ic prednisolone," Dr. Holland said. "We shouldn't assume generics will be cheaper." Manufacturer coupons or discount cards have been another option to help keep costs reasonable, Dr. Holland said. If patients must pay out of pocket, there are a couple of other options. Dr. Sheppard occasionally refers patients to Canadian pharma- cies that can obtain cheaper medi- cations. "In not so serious diseases, we may give the generic and pray they'll be compliant," he said. In Dr. Perry's market, the use of generic prednisolone acetate pro- vides the best value if a patient can't afford difluprednate. Cost issues may be an import- ant consideration, but Dr. Starr also likes to stick to the most efficacious steroid for a given scenario. "I think that's what's best for treating pa- tients. If there is a patient call about prohibitively high cost, which is quite rare, then I'm happy to switch to the next best option," he said. Although Dr. Verdier prefers generics unless there is a clear advantage with a branded drug, he has also found generics can be high priced. "My office staff checks weekly to see where the best prices may be, often through mail order, and we share that information with patients," he said. To assist with compliance issues, Drs. Holland and Sheppard said they are looking forward to greater availability of steroid implants with sustained release delivery and inject- able options. EW Reference 1. Foster CS, et al. Durezol (difluprednate ophthalmic emulsion 0.05%) compared with Pred Forte 1% ophthalmic suspension in the treatment of endogenous anterior uveitis. J Ocul Pharmacol Ther. 2010;26:475–83. 2. Sheppard JD, et al. Difluprednate 0.05% versus prednisolone acetate 1% for endoge- nous anterior uveitis: a phase III, multicenter, randomized study. Invest Ophthalmol Vis Sci. 2014;55:2993–3002. Editors' note: Dr. Holland has finan- cial interests with Alcon and Allergan. Drs. Perry and Sheppard have financial interests with Alcon, Allergan, and Bausch + Lomb. Dr. Starr has finan- cial interests with Alcon and Bausch + Lomb. Dr. Verdier has no financial interests related to his comments. Contact information Holland: eholland@holprovision.com Perry: hankcornea@gmail.com Sheppard: docshep@hotmail.com Starr: cestarr@med.cornell.edu Verdier: daverdier@aol.com

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