EyeWorld Asia-Pacific June 2018 issue

68 EWAP PHARMACEUTICALS June 2018 Zeroing in on Xiidra by Maxine Lipner EyeWorld Senior Contributing Writer What to know about this dry eye agent W hen a patient has dry eye, many practitioners these days are prescribing Xiidra (lifitegrast, Shire, Lexington, Massachusetts), according to Edward Holland, MD , professor of ophthalmology, University of Cincinnati. “It’s the first new drug approved for dry eye since Restasis [cyclosporine ophthalmic emulsion, Allergan, Dublin, Ireland] was approved 14 years ago.” At the heart of lifitegrast’s ef- ficacy is its mechanism of action. “It’s a small molecule, integrin antagonist,” Dr. Holland said. Normally when ICAM-1 and LFA-1 interact, it results in increased T-cell activation with an effect on the whole inflammatory cascade. Lifitegrast interferes with that, he explained, adding that it inhibits the T-cell migration. “It reduces cytokine release and stops further T-cell recruitment.” First line agent For some, lifitegrast is the first medication to try. “In patients who have inflammation associ- ated with their dry eye, it’s my first line therapy,” Dr. Holland said. He pointed to the young to middle-aged women with contact lens intolerance who are known to have inflammation. In addition, there are a significant number of patients who have meibomian gland disease who also have a component of inflammation. In these mixed mechanism dry eyes, he likewise selects lifitegrast as his first line therapy, even in cases that may not appear to be all that severe. Dr. Holland thinks that the scale of what is significant dry eye is skewed, due in part to the way it is diagnosed. “Unfortunately, by what many clinicians believe are early signs of dry eye (conjunctival injection and fluorescein stain- ing of the cornea), we’re actually diagnosing severe dry eye,” Dr. Holland said. “Many patients with moderate dry eye have no conjunctival injection or corneal staining and they’re symptomatic every day.” In Dr. Holland’s view, dry eye should be diagnosed earlier. He cited the fact that there is a big disconnect between signs and symptoms. “Early dry eye patients are very symptomatic and may have minimal to no signs,” he said. For example, a young woman who is contact lens intolerant may have minimal to no signs of dry eye; her conjunctiva is not injected and she has no fluorescein stain- ing of the cornea, but she can’t wear her contacts and her eyes are uncomfortable. Some might miss such moderate dry eye. “We should look to other things like tear osmolarity to help us make an early diagnosis,” he said. “Many clinicians only diagnose the more severe cases.” John Hovanesian, MD , Har- vard Eye Associates, Laguna Hills, California, thinks reaching for lifitegrast early in the treatment regimen makes sense. “We usually think of medications as falling later in the treatment spectrum because we think of them as a long-term commitment,” he said. Yet practitioners are now view- ing this as a vision-threatening lifelong disease that will only get worse if it is undertreated. “We treat symptoms with lubricant drops and warm compresses and simple patient-dependent maneu- vers,” he said. “But we have to treat the underlying disease, the inflammation in the eyelids as well, and that’s where lifitegrast even for mild to moderate cases of dry eye is appropriate in the treat- ment spectrum.” Dr. Hovanesian uses lifitegrast in two common scenarios. The first is the garden variety patient with moderate dry eye who is having some lifestyle impair- ment and who has some signs or symptoms that suggest dry eye. “We put patients on lubricants, warm compresses, and omega-3s,” Dr. Hovanesian said, adding that it becomes a judgment call in many cases whether to initiate lifitegrast at the start or see how they are Dry eye as noted with fluorescein staining Source: Eric Donnenfeld, MD