EyeWorld India March 2019 Issue

60 March 2019 EWAP CORNEA Xiidra out of the comfort zone by Maxine Lipner EyeWorld Senior Contributing Writer Managing lifitegrast pseudo-failures M any practitioners are now reaching for Xiidra (lifitegrast, Shire, Lexington, Massachusetts) 5% for dry eye cases, but sometimes a patient may not initially be considered a success. Here’s what leading practitioners are doing to help more patients find respite with Xiidra. Edward Holland, MD, professor of ophthalmology, University of Cincinnati, pointed out that Xiidra is one of the fastest growing pharmaceuticals in ophthalmology. “Already, many dry eye patients have benefited from it, including a significant number of patients who were Restasis [cyclosporine, Allergan, Dublin, Ireland] failures,” he said. The patients he typically looks to put on Xiidra are young to middle-aged women with aqueous tear deficiency as their primary cause of inflammatory dry eye. However, when the dry eye is very early, some patients may be overlooked for Xiidra. “Patients may present with significant symptoms because they’re early on in the disease course, but they don’t have a lot of clinical signs of dry eye,” he said. “If you control inflammation, you could turn that patient around.” In these early symptomatic patients, Dr. Holland recommends listening carefully to the patient’s history and using lissamine green to pick up interpalpebral staining instead of using fluorescein to detect dry eye. There are some patients who have complaints of redness, burning, and pain when starting on Xiidra, Dr. Holland noted. When burning does occur, he finds that use of loteprednol first can be helpful. He cited a study he took part in that considered the question of loteprednol pretreatment prior to initiation of Restasis. 1 The trial showed improved patient acceptance of Restasis as well as efficacy of the drug. While such burning is less frequent with Xiidra, Dr. Holland will use steroid induction therapy with loteprednol in two types of cases. This includes patients who voice early complaints of burning and stinging when first placed on Xiidra, as well as those who may have significant inflammation from severe dry eye such as Sjögren’s syndrome, Stevens-Johnson syndrome, and graft-versus-host disease. With the first kind of patient, Dr. Holland will stop the Xiidra and initiate loteprednol for 2–4 weeks. In the case of extreme dry eye, he will initiate loteprednol first for this same period depending on their clinical response before introducing Xiidra. Henry Perry, MD, chief of the cornea service, Nassau Relatively severe dry eye with aqueous deficiency had almost complete resolution in 1 month of treatment with Xiidra. Source: Henry Perry, MD