EyeWorld Asia-Pacific September 2014 Issue

September 2014 24 EWAP GLAUCOMA New glaucoma treatments in the pipeline A new class of agents and long-acting therapy on the way N ew glaucoma medical treatments are likely to be in the offering soon and will be a welcome addition for practitioners, believes Steven T. Simmons, MD , associate clinical professor, Albany Medical College, Albany, NY, U.S. “I think there is a tremendous need,” Dr. Simmons said. “We haven’t had a new class of medicine in our field for the last 15 to 17 years.” Because so much time has passed since something new was offered, problems with current medicines are beginning to arise. “Because we’re in the second decade of using these medicines, a lot of patients, especially in a tertiary care office like mine, are AT A GLANCE • The new class of Rho-kinase inhibitors works for 24 hours a day and appears to lower pressure. • New spins on latanoprost are being developed including a preservative-free and long- lasting option. • One latanoprost possibility includes a version with a nitric oxide-donating side chain that appears to boost efficacy. • Unique long-lasting approaches from new agents to pellets and contact lenses could replace drops. by Maxine Lipner Eyeworld Senior Contributing Writer starting to [become] intolerant to classes of medicine,” Dr. Simmons said. “Patients may be allergic to sulfonamides so it eliminates the topical carbonic anhydrase inhibitors; they’ve developed an allergy to brimonidine, or they’re starting to develop some orbital issues related to the prostaglandin analogues—so the more classes available, the better off we are.” New emerging agents A new class that Dr. Simmons sees as bringing fresh hope is the Rho-kinase inhibitors. “This is an outflow drug that we believe works 24 hours a day, 7 days a week,” he said. “That’s important because of the 4 major classes, only 2 work 24 hours a day, 7 days a week—the other 2 classes only work while we’re awake.” In phase 2 testing, the Rho-kinases appear to be lowering pressure approximately 25% from the untreated baseline, he noted. “This may be on the low end of the various phase 3 studies that brought the prostaglandin analogues to market, but may be equal to or better than the beta blockers and alpha agonists,” Dr. Simmons said. These seem to give a specific rate of pressure lowering irrespective of what the baseline pressure is, he said. “It’s the old adage: Would you rather have a drug that you know 50% of the time lowers the pressure 10 mm of Views from Asia-Pacific FANG Seng Kheong, MD The Tun Hussein Onn National Eye Hospital 22, Lorong PJU 3/23F, Sunway Damansara, 47810 Petaling Jaya, Selangor, Malaysia Tel. no. +603 79561511 Fax no. +603 79576128 skfang@gmail.com A lthough the current topical drugs available for lowering IOP in the treatment of glaucoma are more effective and tolerable than 20 years ago, it is still not ideal in many situations. In the Asia-Pacific region, where access to healthcare is not available and affordable in many regions, the main issue is achieving compliance and adherence in patients taking life-long medication for the treatment of a chronic disease which many of them do not understand that will eventually lead to blindness. According to the Asia Pacific Glaucoma Guidelines 2nd Edition , the main goal of glaucoma treatment is to ”maintain functional vision throughout patient’s lifetime with minimal effect on their Quality of Life”. 1 The ideal drug is the one that can achieve the target IOP, with the best safety profile, minimally inconvenient, and affordable. 1 The current gold standard are the prostaglandin analogues (PGA) but it also has issues in addition to causing periorbital skin pigmentation, it also commonly causes associated periorbitopathy, 2 which is fairly common in Asia, and patients, especially younger women, are not keen to apply the medications for cosmetic reasons. The other available drugs have issues with systemic side effects and local allergic reactions. A new class of medication which can achieve the above would be greatly welcomed. Cost and access to healthcare has always been a major issue in the Asia- Pacific region and patients would not adhere to the topical even once-a-day medication due to inability to afford or obtain the eyedrops. As such, long-acting therapy would be ideal if it is made affordable. Bioerodible sustained released medications that can be effective for at least 3 to 6 months would be ideal and patients are not required to remember to instil drops every day. References 1. Asia Pacific Glaucoma Guidelines , 2nd edition, 2008, Scientific Communications. 2. Inoue K, Shiokawa M, Wakakura M, Tomita G. Deepening of upper eyelid sulcus caused by 5 types of prostaglandin analogs. J Glaucoma . 2013;22(8):626–31. Editors’ note: Dr. Fang has no financial interests related to his comments.