EyeWorld Asia-Pacific June 2018 issue

69 EWAP PHARMACEUTICALS June 2018 faring with natural measures first and begin this only if they are not improving. The second scenario is in the presurgical cataract patient who needs to get his or her ocular surface tuned up. “While I used to treat my preop patients with a steroid to get their ocular surface smooth for biometry, we know that steroids work well, but they’re a temporary solution,” Dr. Hovane- sian said. “The patient is not going to stay on steroids forever after surgery.” So at that stage he reaches for lifitegrast. He puts patients on it for 1 month before doing biometry, which enables him to get accurate readings, then may keep patients on it if they continue to show signs of dry eye. He also tests all such preopera- tive cataract patients for MMP-9 and tear osmolarity levels, since dry eye often plagues this age group. “I find a surprising number have high MMP-9 and positive elevated osmolarity,” he said, add- ing that it’s important to identify this because in older patients the symptoms tend to go away as they get desensitized to ocular surface damage. Cynthia Matossian, MD, Matossian Eye Associates, Doyles- town, Pennsylvania, first tries nat- ural measures. “I have something called my ‘starter triad,’” she said. This includes preservative-free arti- ficial tears, an oral omega-3 supple- ment, and a microwaveable heated mask. In addition, she includes a lot of education for patients about dry eye. “I find that starting them on more natural products provides them with the opportunity to wrap their heads around the fact that they have a chronic disease that’s progressive and requiring lifelong treatment,” she said. Dr. Matos- sian brings such patients back after about 8 weeks, allowing time for the omega-3 supplement to kick in. She then repeats MMP-9 testing, as well as tear osmolarity. “If the InflammaDry test is positive, I start them on Xiidra,” she said. If the patient’s insurance plan allows for this, Dr. Matossian will write a prescription for Xiidra. Sometimes, however, the product is not covered, or a pre-authorization is required, in which you have to prove that the patient has used artificial tears or Restasis and failed with these in the past. Discussing potential side effects In cases where the patient is placed on Xiidra, Dr. Matossian always mentions the potential side effects. “I tell them about the dysgeusia and the discomfort or irritation upon instillation,” she said. “This way we minimize calls from concerned patients.” Then Dr. Matossian brings the patient back in another 2 or 3 months, even though she knows lifitegrast typically works quicker. This gives the patient a chance to get used to adding a prescription medication to their daily regimen and time for them to notice improvement in their symptoms. “I tell them it’s a stackable disease; we stack different treatments until I can document objective improvement and the patient notices increased comfort with their eyes,” Dr. Matossian said. “When I see patients back, most are pleased with the results they’ve gotten with Xiidra.” Occasionally there are some who are unhappy with the medica- tion, she noted. “A few patients say, ‘The burning was too much,’ or I had one person say ‘The taste was horrific.’” Dr. Hovanesian likewise gives patients the potential downside of lifitegrast upfront. “I give them every bit of information that could derail their success,” he said. “I tell them it can be pricey, and we always offer information on the access program.” He also details the issues with stinging as well as the altered taste that may arise, explaining that both of these tend to get better over time. To deal with the taste, he advises patients to brush their teeth after they’ve taken it to help get the flavor out of their mouth. Dr. Holland’s response with the lifitegrast has been excellent in most cases. However, he cautions that as with any of the anti-inflam- matories, you’ve got to pick the right patient. “The elderly patient with severe meibomian gland dis- ease or atrophic meibomian glands and a rapid tear breakup time and no inflammation is not going to re- spond to an anti-inflammatory. But if you pick your patients correctly, I’ve found lifitegrast to be quite successful,” Dr. Holland said. Comparing with cyclosporine In his practice, Dr. Holland finds that more patients do better with lifitegrast than cyclosporine as first line therapy. That’s not to say that this is true for everyone, he stressed. “If I have a patient who’s doing well with cyclosporine, I don’t change the therapy,” he said. For the classic patient who he would have put on cyclosporine as his first line of therapy, he now first tries lifitegrast and reserves cyclosporine for those patients who don’t respond. “I do have a small number of patients who fail lifitegrast who will do OK on cy- closporine. But it’s more common and more successful when starting lifitegrast first over cyclosporine,” Dr. Holland said. Dr. Hovanesian pointed out that he also has certain patients for whom cyclosporine works when lifitegrast doesn’t. “But the benefit that lifitegrast seems to have is that it works faster,” he said, adding that about 80% of cyclosporine patients don’t know whether or not the drug is helping them. However, with lifitegrast there is a clearer link in patients’ minds, he finds. “They start to see a benefit in just continued on page 70