EyeWorld India March 2016 Issue

62 EWAP PHARMACEUTICALS March 2016 patients to extra molecules and increase their risk of side effects, which is seemingly the most logical reasoning in the world.” But in some cases, it turns out that the combined safety profile may not be double the side effects, and there may be some synergy to the way the molecules work, he said. With the aid of fixed combinations, practitioners can determine more rapidly whether drugs are going to work for the patient. Dr. Radcliffe cited a November 2002 article that appeared in Ophthalmology that showed there are many combinations that practitioners could try on any glaucoma patient. However, at some point it becomes a question of whether the patient is actually treatable with medication. With fixed combination therapy, it may be possible to arrive at this conclusion much sooner. “I think that most of us would agree that if you have a patient who is on a prostaglandin analogue with one of the fixed combination agents, they’re almost on maximum therapy,” Dr. Radcliffe said. “If you do that in two office visits, then you’ve treated that patient very efficiently and you can get them to whatever their definitive therapy is going to be.” Considering single agents? Still, some think that there is a role for single-dose therapy even with more moderate disease. “Some physicians will do what’s called risk stratification where if they have a patient who just needs a little pressure lowering but is very close, they will just use a single agent,” Dr. Radcliffe said. “Their argument would be, ‘It’s generic; I can do a once-a- day timolol. If someone is way out of control, I’ll add a fixed combination, but if they’re close and just need a little more, I’ll use a single agent.’” However, there are other physicians who work on the principle that no one is safe from glaucoma and that it’s only going to get worse so they don’t want to be on the team that underestimates glaucoma. Dr. Radcliffe falls into this camp. “The rationale there is [we should try to] get ahead of the glaucoma,” he said, adding that while two agents at the moment might be a bit more than is needed, he would rather be ahead of glaucoma than chasing after it. Those who are glaucoma specialists who see more severe cases and who do tertiary referrals tend to be more aggressive right off the bat. “Physicians who are blessed to have patients who are doing better have the luxury of adding just one medicine at a time,” he said. Dr. Parekh usually starts with a single-dose medication such as the prostaglandins with a drug like Xalatan (latanoprost, Pfizer, New York), Lumigan (bimatoprost, Allergan), or Travatan (travoprost, Alcon). “Those are nice because they’re once a day, and they’re powerful in how much they bring down the eye pressure,” he said. But if the patient has issues with prostaglandins and these are not going to work as the first choice, it becomes a question of whether to use one of the fixed combinations or perhaps just timolol. “The timolol once a day is an attractive regimen. I typically prescribe it every morning and that’s all I dose,” he said. “But using the combination medications typically has more of an effect, so it’s very specific to the situation and how much lower the pressure needs to be.” If the patient just needs the pressure down a few points, the practitioner could just add timolol and get the patient’s pressure down enough, he explained, adding that each situation is different. Dr. Radcliffe is inclined to use fixed combinations. He tends to favor Combigan because he thinks that patients will remember this name better than the generic combination of dorzolamide hydrochloride and timolol maleate, which he finds also has a sting to it. There have been several head-to-head studies comparing Combigan and Cosopt where Combigan has had an edge in terms of efficacy. “It does have good data for its efficacy added to latanoprost.” Meanwhile, he thinks that Simbrinza, which is newer to the market, provides a valuable option for patients who have asthma or who can’t tolerate a beta blocker. A couple of new combinations may be coming down the pike. The drug Roclatan (Aerie pharmaceutical, Bedminster, NJ) combines Rhopressa and latanoprost. So far this has completed phase 2B FDA clinical trials, Dr. Radcliffe said, adding that if this is approved, it will be the first fixed combination in America to include a prostaglandin analogue in conjunction with another agent. In addition, currently in Mexico there is a triple fixed-combination agent known as Krytantek (Laboratorios Sophia, Jalisco, Mexico) that combines brimonidine, timolol and dorzolamide. With patients requiring a variety of fixed combinations for individual reasons, the more combinations available, the better, Dr. Radcliffe thinks “The FDA has been a little restrictive, but I think [from a physician’s standpoint], we want all of the options on the table,” he said. EWAP Editors’ note: Dr. Parekh has financial interests with Alcon, Allergan, and Bausch + Lomb (Bridgewater, NJ). Dr. Radcliffe has financial interests with Allergan. Contact information Parekh: parag2020@gmail.com Radcliffe: drradcliffe@gmail.com Coupling - from page 61