Eyeworld

EW GLAUCOMA 96 February 2018 by Maxine Lipner EyeWorld Senior Contributing Writer Pharmaceutical focus Eye on compounded glaucoma drops What practitioners are considering when it comes to these medications G laucoma drops today are not limited to brand name and generic medications that patients can pick up at their local pharmacy. Many are also turning to com- pounded glaucoma medications such as Simple Drops (Imprimis Pharmaceuticals, San Diego) and Omni (Ocular Science, Manhattan Beach, California) to circumvent a variety of issues, according to Nathan Radcliffe, MD, assistant professor of ophthalmology, New York Eye and Ear Infirmary, New York. EyeWorld took a closer look at compounded drops in the glaucoma arena. Gary Novack, PhD, president, PharmaLogic Development, San Rafael, California, and visiting professor of pharmacology and ophthalmology, University of Cal- ifornia Davis School of Medicine, Sacramento, pointed out that for centuries pharmacists have followed physicians' orders on compounding personalized products on a patient by patient basis. "U.S. food and drug law allows physicians to customize therapy for individual patients, including off-label use of products as they deem therapeutic for the patient," Dr. Novack said. "Com- pounding pharmacies have played a special role in this therapeutic process." For example, oral cyclo- sporine was being compounded into a topical product in the 1900s before a commercial ophthalmic cyclospo- rine was approved by the FDA, Dr. Novack noted. Considering compounded drops Practitioners today are bringing such drops into their glaucoma practic- es. Dr. Radcliffe sees compounding medications as making sense for patients in many respects. He cited the ability to avoid mix-ups by com- bining several glaucoma drops into one bottle. "The main issue I have to combat is patient confusion," he continued on page 98 Day 1 postoperative photograph of a patient who underwent cataract extraction with intravitreal placement of triamcinolone and moxifloxacin. While the patient is likely to notice some floaters, the patient will likely not require any topical therapy following surgery. Source: Nathan Radcliffe, MD " When patients are on four drops, the probability of them coming back and not having run out of at least one of them is low. If they just have one drop to worry about, that's more manageable. " —Nathan Radcliffe, MD said, adding that it's not uncommon for a patient to take the timolol cap, for example, and put it on the prednisolone bottle. This can cause them to take the wrong dose of the medication. "After surgery, you may ask, 'Are you using the bottle with the pink cap four times a day?" Dr. Radcliffe said. While patients may swear they're following directions, when they bring the bottles in for him to review, the mix-up becomes clear. This tends to happen more with those who have a lower level of health literacy, he finds. With this in mind, Dr. Radcliffe uses compound- ed medications for both glaucoma and cataract care. Even when there are no mix- ups, in terms of compliance, reduc- ing the number of drops needed can be a boon for patients. "We know that patients have trouble with just two eye drop bottles," Dr. Radcliffe said. He finds that compliance drops off, and instead of doing patients a favor by adding a medicine to the regimen, their glaucoma may end up being under worse control than ever, with gaps in therapy. "When patients are on four drops, the prob- ability of them coming back and not having run out of at least one of them is low," he said. "If they just have one drop to worry about, that's more manageable." In addition, using just one com- pounded medication can potentially reduce exposure to preservatives, Dr. Radcliffe pointed out. Preservative exposure is much greater if patients are taking drops from four separate bottles instead of just one. The market may also be ripe from a financial standpoint. Dr. Rad- cliffe said that the generics market has seen a steep increase in prices lately. "We have an entirely gener- icized market, which means that some of the leading formulations from each class of medications are available," he said. "This should be a time of amazing savings for glau- coma patients, but some patients are paying as much for generic medicine as they would for brand name medication." This is because the prices are often controlled at the pharmacy and not by the generic manufacturer, and many institu- tions and insurance formularies insist that practitioners prescribe these generic drugs. "When you don't have the choice, there's the ability for generic manufacturing pharmaceutical com- panies to raise prices," Dr. Radcliffe said. As a result, it's not uncommon to have a glaucoma patient who is on three generic medications pay- ing more than $100 in copays per month. For some patients in this sit- uation, it may make sense to switch to a more affordable compounded medication. The question becomes, does a patient on four separate glau- coma medications typically have a copay that's greater than $50 per month? "The answer is about half the time," Dr. Radcliffe said. "So for half of those people, something like this could save them a little money and be easier."

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