EyeWorld India September 2020 Issue

EWAP SEPTEMBER 2020 49 GLAUCOMA Interactions between any of the three drugs and other medications have not been reported. Challenges to prescribing “From a strictly clinical standpoint, these medications check off all boxes for characteristics we look for in first-line treatments,” Dr. Lee said. However, all three doctors noted challenges to prescribing new medications. In addition to the standard challenges of prescribing any medication—familiarity and comfort of the prescribing physician and the ability and acceptance of patients to incorporate new medications or changes into their routine, Dr. Serle said—all three doctors noted that the main challenge is insurance coverage limitations and prior authorization requirements. “Clinicians’ offices can be overburdened with prior authorization requests,” Dr. Khouri said. Despite being seemingly ideal as first- or second-line treatment, Dr. Lee thinks the new agents are currently impractical, in many cases, due to cost and insurance coverage. Also, due to the significant drop in adherence with each additional medication, adding these medications onto an “already medically maximized patient certainly does not help from a compliance standpoint,” he said. Dr. Khouri emphasized giving each patient more chair time as therapy is individualized and so patients are prepared for side effects. Utilization, existing treatment, transition to surgery While agents are “well- positioned as first-line medications,” Dr. Khouri said, they can also be integrated into the glaucoma treatment algorithm “as add-on medications in patients not sufficiently controlled,” Dr. Serle said. Dr. Khouri sees these newer agents, dosed once a day, as an opportunity to simplify treatment regimens. “Maximal therapy can be as simple as two bottles now,” he said. In compliant patients who reliably administer their medications and achieve target IOP, Dr. Serle said that numerous topical ocular hypotensive medications are “acceptable and beneficial. If target IOP is not achieved in a compliant patient, substitution or addition of newer medications can be considered.” Real-world studies have shown both latanoprostene bunod and netarsudil to provide additional IOP reductions in patients already taking three or more medications. While there is currently no real-world data for the additive effect of the more recently approved, fixed-dose combination, the experience with each component alone makes this the anticipated result. Both Dr. Khouri and Dr. Serle see surgery as “the next discussion” for progressing patients not meeting target IOP on medications. Surgical intervention, Dr. Lee said, is now “a much more reasonable option in many cases,” given the improved safety profile of microinvasive techniques and devices. “On the other hand, a MIGS procedure in the wrong patient can potentially backfire with visually significant IOP spikes or large hyphemas,” he said. “The decision to add more medications vs. surgery should be made on a case-by-case basis.” In patients already on a prostaglandin analogue, side effect profile and desired IOP reduction play a major role in deciding whether to switch to latanoprostene bunod or the fixed combination. “Both medications in this scenario would be a fine choice,” Dr. Lee said. “In eyes where I’m seeking to reduce IOP by more than 2 mmHg, I am more likely to try Rocklatan first as it had a slight edge over Vyzulta compared to latanoprost alone in the MERCURY and VOYAGER trials, respectively. In eyes where I am concerned about significant hyperemia, I am more likely to try Vyzulta first due to its comparatively favorable side effect profile.” In any case, Dr. Serle reminded clinicians that potential side effects of all treatment options need to be discussed with each patient. The actual impact on disease progression also remains an uncertainty and patients should be informed as such. “Studies need to be conducted to determine if the disease may progress at a slower rate, particularly if these agents are added early in the course of glaucoma,” she said. EWAP References 1. Weinreb RN, et al. Latanoprostene bunod 0.024% in subjects with open- angle glaucoma or ocular hypertension: pooled Phase 3 study findings. J Glaucoma. 2018;27:7–15. 2. Weinreb RN, et al. A randomized, controlled comparison of latanoprostene bunod and latanoprost 0.005% in the treatment of ocular hypertension and open angle glaucoma: the VOYAGER study. Br J Ophthalmol. 2015;99:738– 745. 3. Fechtner RD, et al. Pooled efficacy analysis of once-daily netarsudil ophthalmic solution 0.02% in patients with ocular hypertension or open-angle glaucoma. 2018 ASCRS ASOA Annual Meeting. 4. Khouri AS, et al. Once-daily netarsudil versus twice-daily timolol in patients with elevated intraocular pressure: The randomized Phase 3 ROCKET-4 study. Am J Ophthalmol. 2019;204:97–104. 5. Asrani SG, et al. A 3-month interim report of a prospective, double- masked, randomized, multi-center, active-controlled, parallel-group 12-month study assessing the safety and ocular hypotensive efficacy of PG324 ophthalmic solution. 2017 American Glaucoma Society Annual Meeting. 6. Ustaoglu M, et al. The efficacy and safety profile of netarsudil 0.02% in glaucoma treatment: Real-world outcomes. 2019 Association for Research in Vision and Ophthalmology Annual Meeting. 7. Radell JE, et al. Incorporation of the first nitric oxide donating prostaglandin, latanoprostene bunod, into clinical practice. 2020 American Glaucoma Society Annual Meeting. Editors’ note: Dr. Khouri is associate professor of ophthalmology, Rutgers New Jersey Medical School, Newark, New Jersey, and has relevant interests with Glaukos, Optovue, Allergan, New Jersey Health Foundation, Aerie, and Bausch + Lomb. Dr. Lee is clinical instructor of ophthalmology, Wills Eye Hospital, Philadelphia, Pennsylvania, and has relevant interests with Allergan, Optovue, and Glaukos. Dr. Serle is professor emeritus of ophthalmology, Icahn School of Medicine at Mount Sinai, New York, and has relevant interests with Aerie Pharmaceuticals, Allergan, Bausch + Lomb, and Qlaris Bio.