Glaucoma Drugs

The next (July 22, 2013) issue of The Medical Letter will include an article on a new combination of 2 old drugs for treatment of glaucoma. The pharmacotherapy of glaucoma, which we reviewed in our November 2012 issue of Treatment Guidelines from The Medical Letter, is complicated. Prostaglandin analogs, which are usually tried first, increase uveoscleral output. Beta blockers decrease aqueous humor production, as do carbonic anhydrase inhibitors. Alpha agonists both increase uveoscleral output and decrease aqueous humor production. Cholinergic agonists increase the outflow of aqueous humor. All of these agents are given topically, as eye drops.

Self-administration of eye drops can be physically challenging, especially for elderly people with poor eyesight, a description that fits most patients with glaucoma. It can also be intellectually challenging, because the common practice is to prescribe one drug, and then if intraocular pressure does not go down, add another. And then another. All of these drugs have different schedules. Prostaglandin analogs should be dosed once in the evening. Beta-blockers should be instilled in the morning, or sometimes twice a day. Carbonic anhydrase inhibitors are dosed 3 times a day. Cholinergic agonists vary, but at least one of them is dosed qid.

Many glaucoma patients eventually find themselves dropping 3 or 4 of these agents into their eyes at all different times of the day. The difficulty of maintaining such a complicated schedule of medications can be the limiting factor in the ability of these patients to care for themselves. We once suggested in The Medical Letter that perhaps stopping the drugs that have been shown not to work in a given patient would not compromise the treatment, but that suggestion, as far as we can tell, did not lead to a groundswell for monotherapy. Maybe the additive effects are needed. So combinations of drugs in a single product can be a blessing. Depending on a few things we talk about in our next issue. Watch for it.

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