Factors guiding the choice of glaucoma treatment


Neil Minkoff, MD: One of the things I’m trying to understand here is that we talked about prostaglandin analogs being the first step or a foundational drug. One of the things I’m still not sure I understand is when you switch to another 1 vs when you add a new therapy vs when you change classes. This is one of the things that we in managed care struggle with understanding your treatment journey and where changing is appropriate versus adding is appropriate versus a whole new class, especially now that there are new drugs.

Terri-Diann Pickering, MD: Generally, I try to switch classes of prostaglandins due to its effectiveness and the once daily dosage of that class. So if I start with 1 and it doesn’t work, I’ll keep trying, maybe 2 or 3 different drops to see if I can get an answer. The benefit of having a patient on just one drop a day is great. It is important. If I get a partial response with one prostaglandin, that’s when I’ll add a second agent. Again, the benefit of something like the fixed combination with a prostaglandin and netarsudil [Rhopressa] is that you avoid multi-bottle therapy and that helps with compliance.

Nathan Radcliffe, MD: It boils down to a few calculations. If you added any medication to generic latanoprost [Xalatan], you can avoid adding medication by changing a certain percentage of the time, be it 20%, 25% or 15%. But that fraction of patients who are now going to be able to take just the brand name prostaglandin analog instead of 2 bottles are happy about it and they will be more compliant, and their disease will probably be better controlled. It’s a game of fractions, but you’re trying to maximize the PGA [prostaglandin analogs] file, which involves going to brand name therapy, before adding. And you can’t switch from a PGA because even fixed combinations have similar effectiveness. They don’t have better efficiency.

Terri-Diann Pickering, MD: There are many problems with eye drops, but regardless of class, they can all cause burns. They can all cause long-term redness and dryness. They have these negative negative effects. The other thing is the actual dosage of the drops themselves. When inserting the drops, we ask our patients to close their eyes and keep them closed for 3-5 minutes. If you are used to taking one pill and taking another, taking another pill can be done in a minute. Eye drops are not like that. You have to dose them correctly. If you are on 2 drops, it may take you 6-10 minutes. If you are on 3 drops, it may take you 9-15 minutes. It’s a significant amount of time. We look at people who have to do this indefinitely for the rest of their lives and tell them that if they don’t they could go blind. Anything we can do to simplify their plan is worth it.

Neil Minkoff, MD: I understand the concept of the combination and we discussed needing or wanting to have 1 vial. What are the disadvantages ? One of the things we think about in managed care is being able to combine 2 generics before going to a branded combination in 1 bottle. What are the difficulties of having 2 different drugs used not in combination, a predetermined combination, but having 1 eye drop and then another eye drop?

Nathan Radcliffe, MD: I will attack it. There is probably at least twice as much preservative in the patient’s eye. Because most other non-PGA agents are bid [twice a day]. agents, you’re not just doubling the number of eye drop applications, you’re tripling it because they’re going to have to take that second drop twice a day. This is confusing. From the patient’s perspective, there is this effort and this time, as Dr. Pickering just explained. The dryness is going to come faster, but for them there’s probably 2 copays and depending on how things work it may or may not be better even in branded therapy. That’s why we all try to simplify. I know it’s very clear that adherence is tied to diet simplicity. I use the term confusion a lot because maybe a third of my patients take their drops incorrectly. And 1 drop once a day is about, a good portion of patients, that’s all they can handle perfectly. and then anything you add will be taken incorrectly.

Neil Minkoff, MD: When do you switch from monotherapy to combination therapy? How long do you give the patient? What are you looking for in terms of intraocular pressure, etc. ?

Terri-Diann Pickering, MD: When I start taking a drug, I see the patient again in 2-3 weeks and look for an answer, then I decide. If it’s a prostaglandin, do I change it in the class or add an agent? Should I switch to a completely different class? We don’t have to wait that long. The drops work quickly. The longest I would expect would be 3 weeks, but we should find out pretty much right away. Of course, once we have reduced the pressure by a certain amount, we must recheck the patient’s glaucoma tests; their visual fields, their optic nerve scans. If we see that they are deteriorating when we have lowered the pressure by 20%, we know that it must be lowered by an additional 10 to 20%. It may also trigger the need to add or change medication. And we usually recheck the tests in 6-12 months.

Transcript edited for clarity.

Martin E. Berry