EyeWorld India March 2015 Issue

53 EWAP PHARMACEUTICALS March 2015 by Maxine Lipner EyeWorld Senior Contributing Writer The latest on combined glaucoma agents Eyeing this two-pronged approach T hese days about half of glaucoma patients are controlled by monotherapy, while the rest need more than one agent at a time, according to Robert J. Noecker, MD , clinical assistant professor, Yale University, and in private practice, Ophthalmic Consultants of Connecticut, Fairfield, Conn. One way to keep some patients from having to juggle more than one bottle is with the aid of combination medications. “I think we all acknowledge that the Achilles heel of medical glaucoma therapy is compliance,” Dr. Noecker said. By making things simpler for patients, they are more likely to adhere to a regimen. “I think the messaging is much clearer when you have just 1 bottle. So the patient will have 1 copay and 1 thing to pick up versus 2.” Also, patients only have to remember one dosing regimen and keep one bottle on hand, he said. The patient’s side effect profile might also improve because the eye is exposed to fewer preservatives and variable pHs from other agents, Dr. Noecker said. In addition, the drop is more likely to get in the eye as expected. “You can also prevent a washout effect where [patients] put one drop in, and 5 seconds later they put a second drop in,” he said. Alan L. Robin, MD , associate professor of ophthalmology and international health, Johns Hopkins University, Baltimore, agrees that streamlining the process with the use of combination agents is potentially attractive. “It simplifies patients’ lives greatly and makes it easier for them to adhere to their prescribed treatment therapy,” he said. Current options Currently, there are three combined glaucoma medications available in the U.S., Dr. Robin said. These include Cosopt continued on page 54 Views from Asia-Paci c Seng Kheong FANG, MD International Specialist Eye Centre (ISEC) Level 8, Centrepoint South, The Boulevard, MidValley City, Lingkaran Syed Putra, 59200 Kuala Lumpur, Malaysia Tel. no. +603-22848989 Fax no. +603-22844330 skfang@gmail.com I n the Asia-Paci c market (other than Japan), we have available more options for xed combination glaucoma agents, mainly the prostaglandin analogue–beta blocker xed combinations. The following are the available xed combination drugs in most Asian countries: 1. Duotrav (Travoprost/Timolol, Alcon) 2. Ganfort (Bimatoprost/Timolol, Allergan) 3. Xalacom (Latanoprost/Timolol, P zer) 4. Azarga (Brinzolamide/Timolol, Alcon) 5. Cosopt (Dorzolamide/Timolol, Merck) 6. Combigan (Brimonidine/Timolol, Allergan) Simbrinza (Brinzolamide/Brimonidine, Alcon) is not yet available in most Asian markets. As alluded in the article, the advantages of these xed combination glaucoma agents are that of improving adherence and compliance, less side effects from preservatives, less washout effect, it is also cheaper in most Asian markets to use these combined agents. A word of caution for the usage of these combined agents is that many ophthalmologists may tend to use them as rst-line drugs by starting a new patient straight away on one bottle which contains two drugs instead of determining whether each component is itself ef cacious for the individual patient. According to the Asia Paci c Glaucoma Guideline (APGG), one should always start with monotherapy (which is usually a prostaglandin analogue) and monitor to see whether the target intraocular pressure (IOP) is achieved and then switch within the same class of drug or use a different class of medications if the rst is not effective enough. The APGG recommends an addition of a second drug only if the rst is effective but is not able to achieve target IOP, this is where the xed combination glaucoma agent comes in as it greatly improve adherence if we use two drugs in one bottle (the rst three on the list above are only used once a day). Another frequently observed error in prescribing these drugs is that many ophthalmologists tend to use two xed combination agents. This is potentially dangerous as at the moment ALL the combined glaucoma agents available in the Asia-Paci c region contains timolol. Overdosing patients with beta blockers can possibly cause fatal adverse effects such as arrhythmia and acute bronchospasm. Editors’ note: Dr. Fang has no nancial interests related to his comments. Combination agents can make it easier for patients to adhere to a glaucoma regimen with fewer drops to instill and potentiall clearer messaging. Source: Robert J. Noecker, MD