EyeWorld Asia-Pacific December 2016 Issue

December 2016 32 EWAP SECONDARY FEATURE the outflow pathway, restoring the outflow pathway, using or enhancing physiologic outflow apply, and this may be appealing,” said Nathan Radcliffe, MD , assistant professor of ophthalmology, Weill Cornell Medical College, New York. Netarsudil “will become a very interesting drug in that it will probably be a first-line drug for people with normal tension glaucoma,” said Alan L. Robin, MD , professor of ophthalmology, University of Maryland; professor of ophthalmology, University of Michigan; and associate professor of ophthalmology and international health, Johns Hopkins University, Baltimore. “The current medications we have seem to work better in people with higher levels of intraocular pressure (IOP), but that may not be the case here.” Netarsudil This compound is the first to lower episcleral venous pressure, which is “what makes this a special drug,” Dr. Vold said. Because this drug is considered a “pure outflow agent,” it will make “a natural complement to the other drugs we’re already using,” Dr. Radcliffe said. “There’s a bit more potential there because the market is saturated with prostaglandin analogues, and a truly new and unique class of medications hasn’t been introduced in a very long time.” Dr. Vold said the fixed combination of netarsudil and latanoprost may “be the most potent drug we’ve ever had in one bottle.” That noted, entry to the market is still challenging— generic medications cost a fraction of the name brand, and cost does factor into treatment decisions, he said. Incremental improvements in IOP reductions may not be enough to warrant physicians changing their prescribing patterns. Netarsudil monotherapy may have a unique advantage in people with lower pressures and/ or normal tension glaucoma, Dr. Robin said. “That’s where I see its real place being,” he said. “Its use in addition to a prostaglandin will provide some bang for the buck, so to speak. That’s where the combination of netarsudil and latanoprost may end up being a first-line drug.” For patients concerned about iris color changes or lid changes, or who are older with cardiovascular or pulmonary comorbidities, its use as monotherapy may be advantageous, Dr. Robin said. The U.S. market has been without a fixed combination drug that includes a prostaglandin, and Dr. Radcliffe said Aerie’s drug “potentially could be very disruptive because we might be switching patients off their current prostaglandin analogue onto this new fixed combination.” The combination netarsudil/ latanoprost story is equally interesting, Dr. Robin said. Any new glaucoma medication needs to be as safe as a prostaglandin, but work better, and only needs to be administered once daily, he said. The mindset among glaucoma specialists is also starting to change, he said. “I was always taught to start with something that is a single-action drug, and if that doesn’t produce the IOP reductions needed, we’d switch drugs. But today, people jump right into combination drugs. If the combination netarsudil/ latanoprost doesn’t have much more hyperemia than bimatoprost and has more IOP-lowering than a prostaglandin, it’s going to be a blockbuster drug that addresses a true unmet need,” Dr. Robin said. If the FDA approves both netarsudil and the fixed combination, Dr. Radcliffe said, “We’ll have thousands of new potential combinations, which means thousands of new opportunities to benefit our patients and to help find a medical regimen that fits their needs or is tailored to the particular needs of each patient.” Latanoprostene bunod Bausch + Lomb’s latanoprostene bunod has shown noninferiority in clinical studies when compared to timolol, which is likely enough to receive regulatory approval, but may not be enough to warrant a mass change on the part of prescribers, Dr. Robin said. “The drug is going to have to prove superiority to other prostaglandins, not just to timolol,” Dr. Robin said. “If this drug can lower IOP even 4 mmHg better than current prostaglandins, that will be a persuasive argument.” Dr. Vold said he’s cautiously optimistic about the potential prospect of another new medication. “There’s a great deal of potential here, in that latanoprostene bunod has a different mechanism of action,” he said. The nitric oxide-donating aspect “will increase outflow through the trabecular meshwork,” Dr. Radcliffe said. “We expect to see a little bit more potency from latanoprostene bunod than we have with latanoprost. I think more importantly, we’ll start thinking about whether or not mechanism matters.” He continued: “If you think about microinvasive glaucoma surgery, where we’re taking advantage of bypassing the trabecular meshwork and taking advantage of the natural outflow pathway, drugs that enhance outflow through the physiologic way, the natural way, may be preferred over drugs that do other things like undo legal outflow or decrease the production of aqueous humor. I think the conversation is going to move away from just pressure reduction to mechanisms of action, and if we start to think about combining laser trabeculoplasty with MIGS, we may want drugs that are going to facilitate fluid movement going through the eye’s natural outflow pathway.” EWAP Editors’ note: Dr. Radcliffe has financial interests with Bausch + Lomb. Dr. Robin has no financial interests related to his comments. Dr. Vold has financial interests with Aerie Pharmaceuticals and Bausch + Lomb. Contact information Radcliffe : nmr9003@med.cornell.edu Robin : arobin@glaucomaexpert.com Vold : svold@cox.net New - from page 31