EyeWorld India March 2016 Issue

March 2016 Glaucoma treatment 24 EWAP SECONDARY FEATURE Navigating through the sea of glaucoma medications by Lauren Lipuma EyeWorld Contributing Writer Experts discuss their go-to medical treatments, benefits of branded versus generic drops, and the role of laser trabeculoplasty M edical therapy for glaucoma is, in a way, more art than science. In addition to determining which patients need to be treated and how, physicians have to analyze changes in IOP and visual field loss to assess how fast the disease is progressing and when it’s time to move on to the next treatment—changes that are often subtle and different from patient to patient. In addition to those challenges, medical treatments options have expanded greatly in recent years— and will continue to expand as companies develop sustained delivery devices and drugs with new molecular targets. It’s better to have more options, but there’s no definitive guide for determining which medication to use for which patient. Here, three experts share their treatment strategies for newly diagnosed glaucoma and weigh in on the issues of branded versus generic drops, combination drops, and the role of laser trabeculoplasty as a first-line treatment. Prostaglandins: The first line of treatment Most glaucoma physicians agree that prostaglandin analogues (PGAs) are their go-to first-line treatment for newly diagnosed glaucoma. PGAs are effective with once-daily dosing, well-tolerated in the eye, and reasonably priced. The cosmetic changes associated with PGAs are more noticeable when the drops are used only in one eye, so for unilateral glaucoma, Davinder Grover , MD , MPH , Glaucoma Associates of Texas, Dallas, will start with a beta blocker. “In cases where a unilateral beta blocker does not work or is not tolerated, I will occasionally have the patient use a PGA in the fellow eye once a week to minimize the unilateral cosmetic sequelae,” Dr. Grover said. Although most physicians choose PGAs as a first-line treatment, they don’t often agree on second- and third-line treatments. Dana Wallace , MD , Thomas Eye Group, Sandy Springs, Ga., chooses beta blockers as a second-line treatment for efficacy and dosing, but will switch to carbonic anhydrase inhibitors or alpha-agonists for patients who have cardiac or respiratory conditions. “I find that when I am moving into second- and third-line medications, my choice becomes very dependent on medical comorbidities and tolerance of medication side effects,” Dr. Wallace said. “I tailor my choice based on the patient.” Dr. Grover also turns to beta blockers if the patient’s glaucoma is not responding to a PGA. Beta blockers are well-tolerated, have minimal side effects, and have a long history of being safe and effective, he said. If a patient has advanced glaucoma and needs a quick drop in pressure, Dr. Wallace will skip the beta blocker and go straight to a combination drop. “I use combination drops as often as possible once a patient is on more than two medications to try to improve compliance and minimize side effects from preservatives,” she said. For Dr. Grover, if a patient is not controlled on a PGA and a beta blocker, he will move to a fixed combination drop—either dorzolamide/timolol (Cosopt, Merck, Kenilworth, NJ) or brimonidine/timolol (Combigan, Allergan, Dublin, Ireland). In these cases, he will stop the beta blocker and have the patient take the fixed combination drop twice daily. “I think fixed combination medications have been a tremendous advance in our ability to care for glaucoma patients and improve compliance with medications while minimizing the patient’s drop and bottle burden,” he said. If the combination drop lowers the IOP well beyond the target pressure, he will sometimes stop the PGA in the hopes of controlling IOP with just one bottle. “I’m big on compliance and adherence, so if the patient is already on a drop, I might go for SLT [selective laser trabeculoplasty] as the next step,” said Parag Parekh , MD , DuBois, Pa. “If they don’t want SLT, I will go for timolol because I think it’s convenient, it’s a good medication, and it’s inexpensive. If the timolol isn’t working enough or if I think they need a big drop in pressure, often I’ll go for one of the combo meds, either Simbrinza [brinzolamide/ brimonidine, Alcon, Fort Worth, Texas], Combigan, or generic Cosopt. It just depends on how much of a pressure drop I think they need.” Branded versus generic medications The branded versus generic debate adds a layer of complexity