Best practices for topical pharmacologic management of glaucoma
In part 2 of a 4-part panel discussion, optometrists Drs. Schweitzer, Bloomenstein, Dunbar, and Ibach share which pharmacologic agents they use to treat glaucoma and what the MORE trial taught them about combination pharmacologics.
Justin Schweitzer, OD:
Let’s take a little deeper dive into topical management with glaucoma medications, and I will, Mark with a K, I’m going to have you kind of take this one here when I kick the question out. I think we all ought to agree that from a topical drop standpoint, PGAs are where we go initially. Initial therapy or SLT, definitely will touch on the LiGHT trial here in a little bit plays a role. But what do you do, Mark, after you have a patient that maybe you’ve started on a prostaglandin analog and they’re progressing on you, what are your next steps?
Mark Troy Dunbar, OD:
I guess it goes back to really what Mitch said, right? What stage of the disease are they and do you think you can achieve your goal with a monotherapy PGA? If you’re close, I live in Miami-Dade County and we’ve got a large Medicaid population formulary issue. Probably like many of us around the country, we will start with a generic latanoprost. If we’re close, I would like to do a branded, but again, that’s not always possible. Then the question is, are you going to fight the battle in terms of prior authorizations and some of those things? If a patient is commercial insurance, then I will do really more of a branded, like a Vyzulta or something like that, that I know there’s reliability, there’s trust. I know it may get me a little bit more than what I would get with a generic latanoprost.
If I’m far away or more moderate or advanced disease, then it’s adding usually combination therapy, a second choice. It’s between obviously the traditional Combigan versus Cosopt, but now the generics. That’s usually my kind of go-to. I rarely, if I’m going to add a second medication or a second bottle, rarely will it be… I’ve kind of done it over the last several months, I’ve kind of gone back to just sometimes just Timolol. We forgot about how good Timolol is, but usually I would like to do a combination, but rarely will I just do a brimonidine or a dorzolamide in addition to a prostaglandin or prostamide.
Mitch Ibach, OD:
If I have a patient on a single generic PGA and I have the ability to, I’m a big proponent of switching. I like to switch to kind of what I loosely call a PGA plus or a prostaglandin analog where I’m getting another mechanism of action. Latanoprost plus netarsudil, or Rocklatan, we have latanoprostene bunod, or Vyzulta, we’re getting a second mechanism outside of uveoscleral outflow with the PGA. We’re also now going to target trabecular meshwork outflow. I think a lot about mechanisms of action. I also think if I switch rather than add, but I add, like Mark does a lot too, but if I switch, I’m keeping that patient on a single medication, single bottle, and it’s still once daily dosed. Compliance is such a concern. Adding drops in medications, I’ll try to switch first usually.
Marc Bloomenstein, OD:
Yeah, I had a hard…
Mark Troy Dunbar, OD:
Which, that’s the question. Like is it, will you do from a generic to a brand and if that isn’t quite enough… I mean, what’s your number of switches?
Mitch Ibach, OD:
Yeah, I’ll usually go straight from generic to a PGA-plus. I usually don’t go generic to branded, branded to PGA-plus.
Marc Bloomenstein, OD:
I mean, therein lies this almost kind of catch-22 because you want to put patients on branded. Problem is, we have to put them on generics just to demonstrate that it doesn’t work. Then moving them into either a different branded or that’s when I would probably start considering something SLT. But I also think that it kind of goes back to a little bit we just talked about before about that quality of life. I’m moving more towards laser. You mentioned before, Justin, we’re going to talk a little bit about laser, but the adherence to medications is just, it’s horrible. I don’t subscribe to the fact that patients don’t want to do it, they just don’t do it. Anything that I can do, and I’m looking at the sustained-released medications, which I think would be great, but just from a coverage standpoint, we can’t get it. More importantly, you don’t get a lot of doctors that are willing to do it. I’m always kind of thinking of those things when I’m thinking about switching, but I echo what both Mitch and Mark said.
Justin Schweitzer, OD:
I think we’ve all agreed that less is probably better. It doesn’t mean medications are a bad thing by any means. We all utilize them, we utilize them often. Dr. Dunbar, you mentioned you’re probably after adding a second, you’re looking at something different. Mitch was talking about switching to these fixed-combination agents, these kind of cross the prostaglandin pluses. It makes me think of a phase 4 clinical trial that was recently done called the MORE study. Mitch, I know you’re familiar with the MORE study. Do you want to take us a little bit through that briefly on what that study showed us in regards to topical medications?
Mitch Ibach, OD:
Yeah, background on the MORE study. Open-label, multicenter study, it’s what we call a phase 4 clinical trial, so after FDA approval. All patients in the MORE study were on a prostaglandin, a prostaglandin plus another drop or a prostaglandin plus 2 or more medications. You have these patients that are already treated and then all patients were switched to Rocklatan or netarsudil plus latanoprost, taken away the other drops, they’re just now a single agent now. The eye pressure in all groups dropped about 15% to 20% from a medicated baseline or their previous dropped IOP. A secondary really interesting take home for me from the MORE study was patients who are on a PGA plus 2 or more medications actually got more IOP reduction than patients who are on a single PGA or PGA plus 1. I think that speaks to compliance. That patient who’s on a PGA plus 2 or more medications might not be doing any of the medications. They actually saw a bigger IOP reduction in the patients who are on less meds. Excuse me, on more meds.
Justin Schweitzer, OD:
It goes to the point of what you three have said right now compliance matters because that’s the quality of life issues. It goes to the point of less is probably better, but doesn’t mean we shouldn’t be utilizing these things. We have some agents that can get us what we need from an efficacy standpoint. If we don’t get that, then I think we have other considerations.
