Cost considerations of medical therapy for glaucoma

Changes of the Types and Daily Costs of Topical Antiglaucoma Medications from 2006 to 2021 in China

Purpose. To investigate the changes of the types and daily costs of topical antiglaucoma medications from 2006 to 2021 in China, providing evidence for optimizing treatment regimen and medical insurance policy. Methods. The types of topical antiglaucoma drugs except complementary and traditional medicines and associated price information were collected from the largest pharmaceutical database in China (YAOZH database). The daily costs of each drug, the average income level, and the daily cost of topical antiglaucoma medications relative with daily disposable income were calculated and compared between 2006 and 2021. Results. The options of topical antiglaucoma drugs increased remarkably to 32 types in 2021, of which prostaglandin analogs comprised the largest proportion (31.25%). There were 10 types of the same brand drugs available in 2006 and 2021, the mean daily cost of which decreased from $0.39 ± 0.30 to $0.28 ± 0.23 ( $p<0.001$ ). As the average daily disposable income of Chinese residents grew greatly, the proportion of the daily cost of topical antiglaucoma medications in daily disposable income in 2021 declined significantly from 32.52% to 5.78% (all the drugs, $p<0.001$ ) and 3.94% (without unit dose package, $p<0.001$ ) in rural areas and from 9.95% to 2.31% (all the drugs, $p<0.001$ ) and 1.57% (without unit dose package, $p<0.001$ ) in urban areas. Conclusions. Topical antiglaucoma medications available become much more abundant in China. With the increase of residents’ disposable income and reduction of daily costs of topical antiglaucoma medications, the drug treatment for glaucoma becomes more affordable both in rural and urban areas.

Medication Burden for Patients With Bacterial Keratitis

PURPOSE

To understand medication use and patient burden for treatment of bacterial keratitis (BK).

METHODS

A retrospective study was conducted examining medical records of adult patients with BK in an academic cornea practice. Data collected included medications used in the treatment of BK, dosing of medications, and the number and total duration of clinical encounters. Costs of medications were estimated using the average wholesale pharmacy price. Linear regression analysis was used to investigate associations of medication use with patient demographics and corneal culture results and reported with beta estimates (β) and 95% confidence intervals (95% CIs).

RESULTS

Forty-eight patients with BK (56% female) were studied. Patients were treated for a median of 54 days with 10 visits, 5 unique medications, 587 drops, and 7 prescriptions. The estimated median medication cost was $933 (interquartile range: $457-$1422) US dollars. Positive bacterial growth was significantly associated with more visits (β: 6.16, 95% CI: 1.75-10.6, P = 0.007), more days of treatment (β: 86.8, 95% CI: 10.8-163, P = 0.026), more prescribed medications (β: 2.86, 95% CI: 1.04-4.67, P = 0.003), and more doses of medications (β: 796, 95% CI: 818-1412, P = 0.012) compared with patients who did not undergo corneal scraping. Patients were prescribed 132 more drops of medication for every 10 years of older age (β: 132, 95% CI: 18.2-246, P = 0.024). Sex and income were not associated with medication burden or treatment length.

CONCLUSIONS

Older patients and those with positive cultures incur the most medication burden in treatment of BK. Providers should be aware of medication usage and cost burden as it may affect compliance with treatment.

Naturalistic, Prospective Study of Glaucoma and Ocular Hypertension Treatment in France: Strategies, Clinical Outcomes, and Costs at 2 Years

Purpose

To prospectively observe second-line treatment strategies, their clinical outcomes, and treatment costs in patients with primary open-angle glaucoma (POAG) or ocular hypertension (OH) in France.

Methods

Second-line patients were recruited from September 14, 1998, to December 20, 2000, in 37 centers and were followed for up to 2 years. Outcomes were numbers of and reasons for treatment changes, changes in clinical parameters (intraocular pressure (IOP) levels, visual field defects, and optic nerve excavation), and direct medical costs associated with glaucoma management. This article reports results of the final analysis of 2-year follow-up data for patients with at least two contacts with a study ophthalmologist.

Results

Data were analyzed for 346 patients and 672 treated eyes. Monotherapy was used as first-line therapy in 92.0% of eyes. Second-line treatment was initiated an average of 2.8±0.2 years after diagnosis, primarily due to insufficient IOP control (60.3%) and adverse drug reactions (18.3%). Relative risk (RR) (95% CI) for adverse drug reactions (ADR) under monotherapy was 1.00 (1.00–1.00) under beta blockers (n=116) versus 0.40 (0.16–0.64) under latanoprost (n=21), 2.30 under carbonic anhydrase inhibitors (n=29), and 2.90 under adrenergics (n=38); RR for ADR under combination therapy was 1.00 (1.00–1.00) for unfixed combinations without latanoprost (n=66) versus 0.11 (0.00–0.22) for unfixed combinations of latanoprost + timolol (n=3). Cardiac or pulmonary problems have been reported in 26.9% of patients. Persistency on initial therapy was 62.5% (95% CI 53.0–72.0) for latanoprost monotherapy versus 41.1% (34.8–47.4) for beta-blocker monotherapy and 43.6% (26.6–60.6) for the latanoprost + timolol combination versus 29.8% (15.2–44.4) for combination therapies that did not include latanoprost. Average daily cost for latanoprost monotherapy was similar to that for patients who failed beta-blocker monotherapy: latanoprost + timolol did not cost more than therapeutic combinations without latanoprost.

Conclusions

Insufficient IOP control and adverse drug reactions are the two main reasons for changing first-line treatment in patients with POAG or OH. After 2 years, second-line treatment with latanoprost, as monotherapy or combined with timolol, provides superior safety and persistency to treatment at an acceptable cost.

Cost of glaucoma treatment in a developing country over a 5-year period

The aim of the study was to disclose a realistic estimate of primary open-angle glaucoma treatment, follow-up costs, and patients' monthly glaucoma-economic burden in an ophthalmology hospital in Mexico City.Prospective survey of 462 primary open-angle glaucoma patients from 2007 to 2012 was carried out. Costs from visits, glaucoma follow-up studies, laser, and glaucoma surgical procedures were obtained from hospital pricings. Education, employment, and monthly income were interrogated. Total cost was divided into hypotensive treatment cost, nonpharmacologic treatment cost (laser and surgeries), and follow-up studies and consults. Average wholesale price for drugs analyzed was obtained from IMS Health data; monthly cost was calculated using: Monthly cost  = ([average wholesale price/number of drops per eye dropper] × number of daily applications) × 30 days.Patients were classified according to their glaucoma severity, and data were analyzed based on monthly income (average annual exchange rate: 12.85 Mexican pesos = 1 USD).The mean age was 70 ± 10 years, women = 81%, elementary school = 39%, and unemployed = 53%. Low-income group = 266 patients (57%), 146 with mild glaucoma; moderate-income group = 176 patients (38%), 81 with mild glaucoma; high-income group = 20 patients (4.3%), 10 with mild glaucoma. Patients' monthly average economic burden in glaucoma treatment: low-income patients = 61.5%, moderate-income patients = 19.5%, and high-income patients = 7.9%.Glaucoma-economic burden is substantial not only for health systems, but for the family and the patient. Therefore, screening plans for earlier diagnosis, and health policies that lessen the cost of disease management and increase adherence to treatment, and reduce the prevalence of blindness attributed to glaucoma are essential. These would improve quality of life, reduce personal and national expenditure, and help increase national economy.

A pharmacoeconomic analysis to determine the relative cost-effectiveness of bimatoprost 0.03% eye drops and brimonidine 0.2% eye drops in patients of primary open-angle glaucoma/ocular hypertension

AIMS

The aim was to compare efficacy and cost-effectiveness of bimatoprost 0.03% and brimonidine 0.2% in primary open-angle glaucoma (POAG)/ocular hypertension (OHT).

SETTINGS AND DESIGN

Open, randomized, cross-over, comparative study.

MATERIALS AND METHODS

Forty patients of POAG or OHT with intraocular pressure (IOP) <30 mm Hg were included in the study after a written informed consent. The patients were divided randomly into two groups of 20 patients each. Patients of group A were administered bimatoprost 0.03% eye drops once daily, and those of group B brimonidine 0.2% eye drops twice daily for a period of 4 weeks. After a washout period of 4 weeks, the patients were crossed over that is, group A was administered brimonidine 0.2% and group B bimatoprost 0.03%. Fall in IOP at 4 weeks was recorded. The daily cost of each drug was calculated by maximum retail price and the average number of drops per bottle. The cost-effectiveness was then calculated as the cost of drug/mm Hg fall in IOP.

STATISTICS

Independent samples t-test was used to compare the efficacy of both drugs.

RESULTS

IOP lowering with bimatoprost (8.9 ± 1.598 mm Hg) was significantly (P < 0.0001) higher than brimonidine (6.55 ± 1.26 mm Hg). The number of drops/ml were 33.43 ± 0.52 and 25.49 ± 0.26, respectively, for bimatoprost and brimonidine. Treatment with bimatoprost was costlier than brimonidine with daily costs/eye Rs. 4.02 ± 0.06 and 3.14 ± 0.03, yearly costs/eye Rs. 1467.46 ± 20.74 and 1147.75 ± 11.15, respectively. Bimatoprost was more cost-effective than brimonidine with the cost-effectiveness ratio (CER) respectively Rs. 13.10 ± 2.61/mm Hg and Rs. 13.96 ± 2.86/mm Hg. Incremental CER Rs. 10.43/mm Hg implies lower costs/mm Hg extra IOP lowering by bimatoprost than Rs. 13.96 for brimonidine.

CONCLUSION

In spite of being costlier, bimatoprost is more efficacious and cost-effective than brimonidine.

Topical glaucoma therapy cost in Mexico

Glaucoma is an important cause of irreversible blindness that represents a significant economic burden; most direct costs of glaucoma are drug-related. We calculated the annual cost of some of the most commonly prescribed glaucoma medications in Mexico, according to their average wholesale price (AWP) and dose regimen. Annual costs ranged from USD4.97 for Imot 15 ml (timolol 0.5 %; Laboratorios Sophia) to USD675.39 for Alphagan 5 ml (brimonidine 0.2 %; Allergan, Inc.). β-Blockers were the least expensive glaucoma medications (range USD20.44-55.44). Alphagan 5 ml was 250 % more expensive than other selective α(2)-agonists. Of the carbonic anhydrase inhibitors, dorzolamide 2 % was less expensive than brinzolamide 1 % (USD326.91 vs. USD418.96). The annual cost for prostaglandin analogs ranged from USD235.58 for bimatoprost 0.03 % to USD337.78 for latanoprost 0.005 %. Some fixed combinations were less expensive than separate combinations. The average annual cost for all treatments increased by 27.87 ± 10.09 % between 2009 and 2012. Annual glaucoma therapy cost seems to be lower in Mexico than in other countries, due to a lower AWP, especially for some medications made by Mexican laboratories.

Costs and persistence of alpha-2 adrenergic agonists versus carbonic anhydrase inhibitors, both associated with prostaglandin analogues, for glaucoma as recorded by The United Kingdom General Practitioner Research Database

The persistence and costs of carbonic anhydrase inhibitors + prostaglandin analogues (CAIs + PGAs) vs alpha-2 adrenergic agonists + prostaglandin analogues (alpha-2 agonists + PGAs) were compared, based on The United Kingdom General Practitioner Research Database. Patients with a diagnosis of ocular hypertension, glaucoma, or treated for this, were selected. Selected patients were prescribed CAIs + PGAs or alpha-2 agonists + PGAs. Treatment failure was defined as a prescription change (adding, removing, or replacing glaucoma treatment, or initiating laser or surgery). Times to treatment failure were compared with a Cox model adjusted by a propensity score. Mean patient age was 69.0 years and 47.6% were males. Treatment failure at 1 year was experienced by 58.8% receiving CAIs + PGAs and 66.0% of patients receiving alpha-2 agonists + PGAs (p < 0.001). The hazard ratio for failure was 0.82 (p < 0.001) in favor of CAIs + PGAs after adjusting on age, gender, comorbidities, and duration of follow-up. Adjusted annual costs of glaucoma management did not differ significantly between treatments, £440.63 with alpha-2 agonists + PGAs and £413.37 with CAIs + PGAs. CAIs + PGAs therapies appear more persistent than alpha-2 agonist + PGA in everyday clinical practice, at a similar cost.

Short-Term Effect of Acupuncture on Intraocular Pressure in Healthy Subjects

Purpose

To evaluate the short-term effect of acupuncture on the intraocular pressure (IOP) in healthy subjects.

Methods

A randomised controlled double-blinded trial was performed. 48 healthy volunteers (94 eyes) were randomly allocated to three groups: acupuncture group—19 subjects (38 eyes) were submitted to a 20 min session of acupuncture (GB1, GB14 and BL1); sham group—14 subjects (27 eyes) were submitted to a 20 min session of acupuncture with needles inserted in false points; and control group—15 subjects (29 eyes) who underwent no intervention. All subjects had the IOP measured by a masked investigator using Goldmann applanation tonometry immediately before intervention, as well as 20 min and 24 h after.

Results

The mean (SD) IOP in the acupuncture group was 17.9 (3.3) mm Hg at baseline, 16.4 (3.9) mm Hg at 20 min and 16.3 (3.3) mm Hg at 24 h. The mean (SD) IOP in the sham group was 18.6 (3.3) mm Hg at baseline, 17.7 (2.6) mm Hg at 20 min and 15.9 (3.6) mm Hg at 24 h. The mean (SD) IOP in the control group was 16.9 (3.5) mm Hg at baseline, 16.5 (3.8) mm Hg at 20 min and 15.8 (3.3) mm Hg at 24 h. There was no statistically significant difference in the IOP variation (post-intervention minus baseline measurements) between groups after 20 min (p=0.13) and 24 h (p=0.21).

Conclusion

Acupuncture in the studied points did not produce significant short-term effect on the IOP of healthy individuals in comparison with control groups. Clinical Trials Registration Number: NCT00639977

Daily cost of ophthalmic solutions used to treat allergic conjunctivitis in Japan

PURPOSE

To estimate the daily cost of various ophthalmic solutions used in Japan for treating allergic conjunctivitis, including nine anti-allergic drugs and six anti-inflammatory drugs.

METHODS

The drops contained in one bottle of each solution were counted. The cost per drop was calculated by dividing the government-controlled standard prices by the total number of drops in one bottle, and the daily cost of therapy was calculated by multiplying the cost per drop by the number of drops to be given per day.

RESULTS

The total number of drops of the anti-allergic drugs in a bottle ranged from 108 to 169 and that of the anti-inflammatory drugs from 100 to 145. The information in the package insert for these solutions recommends application 2-4 times daily. The price of the antiallergic drugs studied ranged from $6.35 to $8.38 and that of the anti-inflammatory drugs studied from $2.02 to $5.20. The daily cost of the anti-allergic drugs studied varied considerably, from $0.26 to $0.57; for the anti-inflammatory drugs the range was from $0.12 to $0.20. Variations in the total number of drops per bottle and in the recommended dosage affect the daily cost of ophthalmic solutions.

CONCLUSIONS

At current prices, the volume of a drop and the dosage had a greater effect on the daily cost than the price of a bottle. Daily cost data may be helpful in selecting ophthalmic products for treating allergic conjunctivitis in settings where the prices of a given drug are relatively uniform.

Intraocular pressure-lowering efficacy of brinzolamide 1%/timolol 0.5% fixed combination compared with brinzolamide 1% and timolol 0.5%

PURPOSE

To compare the safety and intraocular pressure (IOP)-lowering efficacy of brinzolamide 1%/timolol 0.5% fixed combination with brinzolamide 1% or timolol 0.5% alone in patients with open-angle glaucoma (OAG) or ocular hypertension (OHT).

DESIGN

Randomized, double-masked, parallel group, multicenter study.

PARTICIPANTS

Five hundred twenty-three patients were randomized to the study treatments.

METHODS

Patients with OAG or OHT were recruited to the study. Qualifying eyes had IOPs of 24 to 36 mmHg at 8 am and 21 to 36 mmHg at 10 am on 2 eligibility visits after an appropriate washout period from previous treatment. Patients were assigned randomly to either brinzolamide 1%/timolol 0.5%, brinzolamide 1% (Azopt; Alcon Laboratories, Fort Worth, TX), or timolol 0.5%, dosed twice daily and were followed up while receiving therapy for 6 months. At selected sites, additional IOP measurements were performed at 12 pm, 4 pm, and 8 pm during the 2 eligibility visits, at month 3, and at month 6.

MAIN OUTCOME MEASURE

Mean IOP.

RESULTS

Brinzolamide 1%/timolol 0.5% produced statistically significant and clinically relevant reductions from baseline ranging from 8.0 to 8.7 mmHg, which were statistically and clinically superior to that of either brinzolamide 1% (5.1-5.6 mmHg) or timolol 0.5% (5.7-6.9 mmHg). No safety concerns were identified based on an assessment of ocular and cardiovascular parameters and a review of adverse events.

CONCLUSIONS

Brinzolamide 1%/timolol 05% is superior in IOP-lowering efficacy to either brinzolamide 1% or timolol 0.5%.

Meta-analysis of randomized controlled trials comparing timolol with brimonidine in the treatment of glaucoma

This paper aims to compare the efficacy and tolerability of timolol versus brimonidine in the treatment of glaucoma. Comprehensive searches were performed using Medline, Embase and the Cochrane Controlled Trials Register for randomized controlled trials comparing timolol and brimonidine. Two reviewers independently assessed trials for eligibility and quality and extracted data. A random effects model was used to combine studies. Outcome was defined as the absolute mean intraocular pressure (IOP) reduction from baseline to end-point for efficacy, and relative risk (RR) for adverse events. Subgroup analysis and meta-regression were used to explore heterogeneity according to trial design and quality. Ten publications reporting on eight trials with 2387 participants were included in the meta-analysis. Two further trials were commented on qualitatively. IOP reduction was not significantly different between timolol and brimonidine. Weighted mean difference (WMD) of IOP reduction was 0.24 mmHg (favouring brimonidine) with a 95% confidence interval of -0.57 to 1.04 mmHg. There was significant heterogeneity between studies (chi(2) (13) = 73.75, P < 0.00001, I(2) = 91%). Subgroup analysis showed no significant WMD for studies where data were analysed from end-points >/=6 months or <6 months. Meta-regression analysis showed increased WMD IOP reduction in favour of brimonidine with increased trial quality (t(3) = -4.58, P = 0.01), but no significant association with trial duration (t(3) = 0.73, P = 0.51) or size (t(3) = -0.59, P = 0.57). The RR of ocular allergy was much lower with timolol than brimonidine (RR = 0.08, 95% confidence interval 0.01 to 0.47). Publication bias was not evident on a funnel plot, although the number of studies was small. The conclusion is that both drugs are equally effective in lowering IOP. Brimonidine is associated with a higher rate of allergy.

Costs and persistence of carbonic anhydrase inhibitor versus alpha-2 agonists, associated with beta-blockers, in glaucoma and ocular hypertension: an analysis of the UK-GPRD database

OBJECTIVE

To compare the effectiveness and associated costs of carbonic anhydrase inhibitors + beta-blocker versus alpha-2 adrenergic agonists + beta-blocker in glaucoma therapy, as documented by The United Kingdom General Practitioner Research Database (UK-GPRD).

RESEARCH DESIGN

Patient chart analysis.

METHODS

Patient records were screened for diagnoses of ocular hypertension or glaucoma, and for surgery, laser therapy or medication specific to glaucoma. Selected patients were those prescribed either carbonic anhydrase inhibitors + beta-blocker or alpha-2 adrenergic agonists + beta-blocker. Treatment failure was defined as a glaucoma prescription change, i.e. addition, cessation or replacement of medication, surgery or laser therapy. Times to treatment failure were compared with an adjusted Cox model.

MAIN OUTCOME MEASURES

Treatment persistence and cost.

RESULTS

Included patients were those treated with either carbonic anhydrase inhibitors + beta-blocker (n = 5581) or alpha-2 adrenergic agonists + beta-blocker (n = 1164). The average age at diagnosis was 68.1 years and 48.2% were male. Treatment failure at one year was significantly (p < 0.001) less frequent after carbonic anhydrase inhibitors + beta-blocker (57% of patients) than after alpha-2 adrenergic agonists + beta-blocker (64.3%). The hazard ratio for failure was lower (0.82: p < 0.0001) with carbonic anhydrase inhibitors + beta-blocker following adjustment for age, gender, comorbidities and duration of follow-up. Adjusted annual costs of glaucoma management were pound 348.04 for carbonic anhydrase inhibitors + beta-blocker and pound 356.80 for alpha-2 adrenergic agonists + beta-blocker.

CONCLUSIONS

According to UK-GPRD information, glaucoma therapy with carbonic anhydrase inhibitors + beta-blocker is more persistent than with alpha-2 adrenergic agonists + beta-blocker at a similar cost.

Daily cost of glaucoma medications in China

PURPOSE

To determine and compare the daily cost of various glaucoma medications in China.

MATERIALS AND METHODS

The majority of glaucoma medications commercially available in China were included in this research. The total number of drops in 1 bottle of each medication was counted drop by drop. The mean volume per bottle of each medication was calculated. The cost per drop, number of days for both eyes usage per bottle, and daily cost was calculated.

RESULTS

(1) The volume per drop ranged from 0.03 mL (brinzolamide 1%, travoprost 0.004%, bimatoprost 0.03%, and latanoprost 0.005%) to 0.05 mL (timolol 0.5%-Chengrui and pilocarpine 0.5% and 2%-Zhenrui). (2) The cost per bottle ranged from $0.69 (US dollar) (timolol 0.5%-Malaisuan Saimaluo'er) to $40.78 (latanoprost 0.005%). (3) The number of days for both eyes usage per bottle ranged from 52 days (bimatoprost 0.03%) to 11 days (pilocarpine nitrate 0.5%-Zhenrui). (4) The daily cost for both eyes usage from expensive to cheap were latanoprost 0.005%-$0.91, travoprost 0.004%-$0.77, brimonidine 0.2%-$0.61, bimatoprost 0.03%-$0.46, D-timolol 1%-$0.36, brinzolamide 1%-$0.34, pilocarpine 2%-Zhenrui-$0.28, levobunolol 0.5%-$0.25, betaxolol 0.25%-$0.24, pilocarpine 0.5%-Zhenrui-$0.18, pilocarpine 2%-Huming-$0.16, carteolol 1%-Mikelan-$0.15, carteolol 2%-Mikelan-$0.15, pilocarpine 1%-Huming-$0.10, timolol 0.5%-Chengrui-$0.08, timolol 0.5%-Malaisuan Saimaluo'er-$0.03.

CONCLUSIONS

The daily cost of glaucoma medications in China ranged much more wildly than developed countries. These data may be useful in selecting medications for glaucoma therapy. The ophthalmic solution of prostaglandins is powerful in reducing intraocular pressure. However, its high price should be considered when selecting glaucoma medications in China.

A critical review of the full economic evaluations of pharmacological treatments for glaucoma

OBJECTIVE

This literature review aimed to critically assess the 'state of the art' of the full economic evaluations (FEEs) on glaucoma pharmacological treatments. This is the first review that tries to thoroughly assess both costs and consequences of pharmacoeconomic evaluations on glaucoma.

METHODS

A literature search was done on the international databases PubMed and EMBASE, to find all the studies published in English on pharmacological treatments for glaucoma in the period 1997-2006. An economic and a clinical checklist were adopted to analyse FEEs and their clinical sources (CS). Finally, the reliability of the 33 FEEs included in the 15 articles selected was assessed from the health authorities' perspective by applying a critical appraisal checklist of 16 items derived from the economic and clinical variables previously analysed.

RESULTS

The major weakness of the articles reviewed seemed to be the extensive recourse to expert panel opinions and assumptions at each phase of the economic analysis. About one-third of the FEEs even based their clinical efficacy on non-evidence-based sources. The critical appraisal of the CS methodological characteristics showed that their quality was not high either.

CONCLUSION

This review showed that most FEEs on glaucoma suffer substantial methodological limits, mainly due to the scarce quality of available CSs, so public authorities should consider their results very cautiously for healthcare decision making.

Costs and persistence of brimonidine versus brinzolamide in everyday glaucoma care: an analysis conducted on the UK General Practitioner Research Database

OBJECTIVE

To compare the persistence and costs of brimonidine versus brinzolamide therapy according to data collected by the UK General Practitioner Research Database (GPRD).

METHODS

Patients with diagnoses of ocular hypertension or glaucoma, or treated for glaucoma by surgery or laser therapy were identified. Selected patients were prescribed either brimonidine or brinzolamide as monotherapy. Treatment failure was defined as a glaucoma prescription change (adding, removing or replacing a drug, or initiating surgery or laser therapy). Times to treatment failure were compared with an adjusted Cox model using a propensity score method.

RESULTS

A total of 2,172 patients received brimonidine and 485 brinzolamide. Mean age was 69.5 years and 46.4% were male. Age and gender did not differ significantly whereas disease duration was longer with brinzolamide. Treatment failure at 1 year was experienced by 47.7% of patients given brinzolamide and by 55.9% given brimonidine (p<0.001). The hazard ratio for failure was less with brinzolamide (0.79: p<0.001) compared to brimonidine, after adjusting for age, gender, comorbidities and duration of follow-up. Adjusted annual costs of glaucoma management (in pound2005) were significantly (p<0.0042) lower with brinzolamide (pound196) than brimonidine (pound230).

CONCLUSIONS

According to data from everyday practice collected by the UK GPRD, brinzolamide was found to be more persistent than brimonidine when given as glaucoma monotherapy. Patients continued longer with brinzolamide treatment at a lower cost.

Cost analysis of glaucoma medications

PURPOSE

To provide patients and health care providers with calculated yearly costs of topical glaucoma medications.

DESIGN

Prospective, experimental, laboratory study.

METHODS

Using the average wholesale price and common dosing patterns, we calculated the theoretical yearly cost of glaucoma medications.

RESULTS

Calculated yearly cost ranged from $150.81 for generic timolol maleate 0.5% (Falcon Pharmaceuticals, Ltd, Fort Worth, Texas, USA) to $697.42 for Cosopt (Merck & Co, West Point, Pennsylvania, USA), and as high as $873.98 for a three-times-daily dose of Alphagan P 0.15% (Allergan, Inc, Irvine, California, USA). Among brand name beta-blockers, yearly cost ranged between $203.47 for Timoptic 0.5% (Merck & Co) and $657.24 for Betoptic S (Alcon Laboratories, Fort Worth, Texas, USA). Generic beta-blockers consistently were more economical than their brand-name counterparts. Yearly cost of prostaglandin analogs ranged from $427.69 for Travatan (Alcon) to $577.62 for Lumigan (Allergan). The two carbonic anhydrase inhibitors Azopt (Alcon) and Trusopt (Merck & Co), yielded similar economic profiles. Alphagan P 0.15% had yearly calculated costs of $559.08 for twice daily dosing per eye. The generic selective alpha(2)-agonist brimonidine tartrate 0.2% (Bausch & Lomb Pharmaceuticals, Tampa, Florida, USA) costs approximately $352.89 and $529.34 per year for the respective two and three drops daily per eye regimens.

CONCLUSIONS

Nonselective beta-blockers remain the most inexpensive class of glaucoma medications. Bottle size may impact yearly glaucoma medication expenditures. Costs of glaucoma medications may impact decision making in the medical management of glaucoma.

A gap analysis approach to assess patient persistence with glaucoma medication

PURPOSE

To develop an alternative method for analysis of patient persistence with prescribed medications using the prostaglandin class of intraocular pressure (IOP)-lowering drugs as a model.

DESIGN

A retrospective study of prescription refill patterns.

METHODS

Patients with a pharmacy claim for a 2.5 ml bottle of latanoprost, travoprost, or bimatoprost between September 1, 2002 and December 31, 2002 were identified from a retail pharmacy database and were followed up for 12 months. Three separate analyses defined gaps in therapy as spans in excess of 45, 60, or 120 days without a refill for the same medication. Patients were categorized by the number of gaps in therapy and the cumulative length of gaps. A Kaplan-Meier analysis was conducted using a 120-day allowable refill period.

RESULTS

For refill periods of 45, 60, and 120 days, 10.6%, 28.6%, and 77.5% of patients, respectively, had no gaps in therapy, and 32.6%, 53.4%, and 86.5%, respectively, had 30 days or fewer off therapy annually. According to the 45-day threshold analysis, 50.7% of patients had three or more gaps vs 18.5% in the 60-day analysis and none in the 120-day analysis. The Kaplan-Meier curve shows 88.6% and 76.1% of patients were persistent for 120 days and one year, respectively.

CONCLUSIONS

Compared with Kaplan-Meier survival curves, the gap analysis approach may better parallel clinical experience with patient persistence, in which patients stop and restart medications for a variety of reasons over time. This method also may help to identify avenues for investigation of lack of persistency among many patients.

Evaluation of the Xal-Ease™ latanoprost delivery system

PURPOSE

The purpose of this study was to compare drops of latanoprost dispensed using the Xal-Ease (Pfizer Ophthalmics, New York, New York) delivery system with drops dispensed manually.

METHODS

Twenty-four 2.5-mL bottles of Xalatan (Pfizer Ophthalmics) were evaluated with or without the delivery system. Individually dispensed drops were counted. The total volume dispensed was measured to the nearest 10 microL. Statistical analysis compared group means by analysis of variance. P values less than 0.05 were considered significant.

RESULTS

The overall mean volume was 2,850 microL. Overall mean drops per bottle (n = 24) were 90.3 +/- 6.3. Using the Xal-Ease, mean drops per bottle were 93.0 +/- 3.4 and without it, 87.7 +/- 7.5 (n = 12 each).

CONCLUSIONS

With Xal-Ease, mean drops per bottle (5) were statistically significantly greater when compared with standard dispensing (P = 0.0393). This result is accounted for by more consistent individual drop volume and greater volume using the delivery system.

Efficiency of Instillation Methods for Prostaglandin Medications

PURPOSE

The aim of this study was to determine the most efficient methods for instillation of prostaglandin analogs.

METHODS

Drops were dispensed at room temperature from 2.5-mL bottles of bimatoprost, travoprost, and latanoprost. Two determinations of drop count were each made from bottles held vertically, at a 45-degree angle, and horizontally. The total volumes of medication dispensed from each bottle were measured.

RESULTS

The mean number of drops dispensed was 111.0, 105.1, and 76.1 drops for bimatoprost bottles; 81.4, 101.1, and 85.3 drops for travoprost bottles; and 94.3, 88.4, and 67.1 drops for latanoprost bottles, held vertically, at 45 degrees, and horizontally, respectively. The mean volume of medication dispensed per 2.5-mL bottle was 3.17 mL for bimatoprost, 2.54 mL for travoprost, and 3.02 mL for latanoprost. The most efficient instillation methods provided 56 days of bilateral therapy per 2.5-mL bottle for bimatoprost, 51 days for travoprost, and 47 days for latanoprost, with corresponding yearly medication costs of $408 for bimatoprost, $449 for travoprost, and $475 for latanoprost. Yearly savings of $109 to $192 could be achieved by using the most efficient instillation methods, representing 5.6 months of medication saved for patients using bimatoprost, 3.0 months for patients using travoprost, and 4.9 months for patients using latanoprost.

CONCLUSIONS

Health care providers are urged to instruct glaucoma patients in the most efficient method of instillation. For bimatoprost and latanoprost, vertical instillation is recommended, with 45 degrees nearly as efficient, and for travoprost, instillation at 45 degrees is recommended.

Timolol/dorzolamide combination therapy as initial treatment for intraocular pressure over 30 mm Hg

PURPOSE

To determine the intraocular pressure (IOP)-lowering effect of a fixed timolol/dorzolamide combination (Cosopt) for patients with IOP over 30 mm Hg.

STUDY DESIGN

Prospective interventional case series.

METHODS

Eighteen patients being seen on the Wills Eye Hospital Glaucoma Service with at least one eye with an IOP > 30 mm Hg were recruited. None had used any glaucoma medications for at least 1 month. IOP was confirmed by diurnal testing. Cosopt was administered at 9 am and 9 pm. Trough IOP measurements were made at 9 am and peak IOP measurements at 11 am at baseline, 1 month, and 2 months. Pretreatment and posttreatment IOPs were compared using a paired-samples independent t test.

RESULTS

Mean pretreatment IOP was 37.5 +/- 1.0 mm Hg. Baseline posttreatment IOP was 18.4 +/- 0.5 mm Hg (P < 0.01). At 2 months, the mean trough IOP was 21.1 +/- 0.9 mm Hg and the peak, 17.6 +/- 0.6 mm Hg (each, P < 0.01, as compared with pretreatment baseline IOP). One patient did not respond to Cosopt; two had a clinically insufficient response and did not complete the study. Data from these patients were included in the analysis.

CONCLUSIONS

Over 80% of the eyes responded to Cosopt, with an average trough IOP reduction of 40% at 2 months.

Efficacy and safety of a fixed combination of travoprost 0.004%/timolol 0.5% ophthalmic solution once daily for open-angle glaucoma or ocular hypertension

PURPOSE

To compare the efficacy of a fixed combination of travoprost 0.004%/timolol 0.5% every day in the morning with a concomitant regimen of timolol 0.5% every day in the morning, plus travoprost 0.004% every day in the evening; and timolol 0.5% twice daily on the intraocular pressure (IOP) of subjects with open-angle glaucoma or ocular hypertension over 3 months.

DESIGN

Prospective, randomized, double-masked, parallel-group, active-controlled, multicenter trial.

METHODS

Patients comprised adult subjects (n = 403) of either gender with open-angle glaucoma or ocular hypertension in at least one eye. To qualify, the IOP had to be between 22 to 36 mm Hg in the same eye at two consecutive eligibility visits. The primary outcome variable was IOP measured with a Goldmann applanation tonometer.

RESULTS

Mean IOP ranged from 16.2 to 17.4 mm Hg with the combination travoprost/timolol compared with 15.4 to 16.8 mm Hg in the concomitant travoprost + timolol group, from baselines of 23.1 to 25.6 mm Hg and 22.9 to 25.0 mm Hg, respectively. The fixed combination of travoprost/timolol significantly lowered IOP by 7 to 9 mm, similar to the IOP reductions observed with concomitant therapy. The most frequent ocular adverse event was hyperemia that occurred in 14.3% and 23.4% of subjects treated with travoprost/timolol combination and concomitant travoprost + timolol, respectively.

CONCLUSIONS

Travoprost/timolol combination produces greater IOP reductions than the positive control, timolol 0.5%, and reductions that were similar to concomitant travoprost + timolol. This study demonstrates that the fixed combination of travoprost/timolol produces significant and clinically relevant reductions of IOP in a once-daily dosing regimen.

Cost considerations of the new fixed combinations for glaucoma medical therapy

OBJECTIVE

To compare the costs of the new fixed combinations for glaucoma medical therapy.

METHODS

The studied drugs were: Cosopt (5-mL bottle), Combigan (5-mL bottle) and Xalacom (2.5-mL bottle). Five bottles of each drug were obtained from pharmacies, and the medications lot numbers were recorded. To calculate the drop volume, 10 drops and 1 mL of each bottle were weighed with a digital precision scale. Drop volume was calculated by the relation between volume and weight. The cost of each bottle of medication was determined from the average retail price in Canada. The prices were obtained in Canadian dollars (dollars).

RESULTS

The drops of Cosopt (39.60 +/- 0.45 microL) were considerably larger than the drops of Combigan (33.75 +/- 0.60 microL) and Xalacom (30.87 +/- 0.37 microL). The average number of drops per millilitre varied from 25.25 +/- 0.29 (Cosopt) to 32.40 +/- 0.39 microL (Xalacom). Combigan presented the lowest daily cost (dollars 0.87 +/- 0.02) followed by Xalacom (dollars 1.09 +/- 0.01) and Cosopt (dollars 1.22 +/- 0.01). The average cost by year varied from dollars 316.75 +/- 5.59 (Combigan) to dollars 445.96 +/- 5.16 (Cosopt), with a total difference of dollars 129.21 per year of treatment.

CONCLUSIONS

There was a statistically significant difference in average drop size and cost among the three studied drugs. Combigan presented the lowest daily cost followed by Xalacom and Cosopt.

Gold standard medical therapy for glaucoma: defining the criteria identifying measures for an evidence-based analysis

BACKGROUND

Over the past decade, several new medical therapies have become available for the treatment of primary open-angle glaucoma (POAG). A systematic evidence-based approach for identifying an optimal therapeutic agent is lacking.

OBJECTIVES

The aims of this review were to critically evaluate published treatment recommendations for POAG and, based on a systematic review of the literature, to develop criteria that would define a "gold standard" medical therapy that reflects new treatment advances and established therapeutic goals.

METHODS

A MEDLINE search spanning the years 1966 to 2002 and using the search terms gold standard, drug of choice, agent of choice, benchmark, ophthalmology, eye, and glaucoma was conducted and the results reviewed by a panel of 15 experts in the field of glaucoma. Published treatment recommendations for POAG were discussed. Criteria, anchored to medical evidence, for distinguishing a standard of medical therapy for POAG were defined.

RESULTS

The terms connoting a gold standard therapy were found in only 258 of approximately 368,000 ophthalmology-related citations and 53 of almost 23,000 glaucoma citations, validating the need to define therapeutic standards. The lack of recommendations for the use of new classes of ocular hypotensive agents was acknowledged. Criteria identified to evaluate intraocular pressure (IOP)-lowering agents as gold standards included the following: efficacy in reducing IOP consistently over a 24-hour period to a level that will preserve the visual field and protect the optic nerve without inducing tachyphylaxis and tolerance, paucity of local and systemic adverse effects, promotion of patient compliance, and applicability in diverse patient populations.

CONCLUSIONS

These criteria should be employed as measures for evidence-based analyses to evaluate available and future IOP-lowering medical therapies for POAG. The conceptual framework presented may be applicable to other therapeutic areas.

A pilot study of deep sclerectomy with implantation of chromic suture material as a collagen implant: medium-term results

AIMS

A pilot study of the safety and efficacy of deep sclerectomy with a chromic suture implant (DSCI) for open angle glaucoma.

METHODS

This prospective trial involved 23 eyes of 16 consecutive patients with uncontrolled open angle glaucoma. The DSCI procedure involved radial suturing of a 2 mm piece of 1/0 chromic suture as an implant. Intraocular pressure (IOP) measurements and eye examinations were performed preoperatively and regularly postoperatively for up to 66 months.

RESULTS

The mean follow-up period was 36.3 (SD 19.9) months. The mean preoperative IOP was 26.3 (SD 8.5) mmHg. The mean postoperative IOP was 14.1 (SD 2.8) mmHg at month 12, and 16.5 (SD 2.3) mmHg at 36 months. Complete success rate, defined as an IOP lower than 21 mmHg without medication was 77% of eyes at 36 months. Qualified success rate, defined as an IOP lower than 21 mmHg with medication, was 100% at 36 months. Paired t-test and Wilcoxon test analysis of preoperative vs postoperative IOP at 36 months indicated a significant reduction in IOP. Intraoperative complications included rupture of the trabecular meshwork in seven eyes. Exclusion of these patients from the results analysis revealed a mean follow-up of 37.1 months (SD 9), preoperative mean IOP was 25.9 mmHg (SD 4.1), 12-month mean IOP was 13.4 mmHg (SD 2.8), and 36-month mean IOP 16.6 mmHg (SD 2.1). Early postoperative complications included hyphaema in two eyes and dislocation of implant in one eye. One eye developed a central retinal vein occlusion and cataract progression occurred in one eye. The mean postoperative duration of use of topical dexamethasone was 5.4 months (SD 2).

CONCLUSIONS

DSCI using a chromic suture implant provides good control of IOP at medium-term follow-up with few postoperative complications. Prolonged use of postoperative anti-inflammatory medication was necessary.

A Persistency and Economic Analysis of Latanoprost, Bimatoprost, or Beta-Blockers in Patients with Open-Angle Glaucoma or Ocular Hypertension

PURPOSE

The aim of this study was to evaluate differences in the persistency and treatment costs for latanoprost, bimatoprost, or beta-blockers in open-angle glaucoma or ocular hypertensive patients.

METHODS

This study was a retrospective, multicenter, parallel, active-controlled comparison of patients who were prescribed with ocular hypotensive monotherapy between September 1996 and August 2002.

RESULTS

1,182 patients were included. The Kaplan Meier life table analysis showed that latanoprost was continued longest among the groups for the first year of therapy (p=0.02). A significant difference existed between groups in the final intraocular pressure for latanoprost (17.3+/-3.9, N=357), for bimatoprost (18.0+/-3.6, N=146), and for the beta-blockers (17.9+/-3.7, N=335) (p=<0.0001). The average number of visits was statistically higher for beta-blockers (3.3), compared to latanoprost (2.9) and bimatoprost (3.1) (p=0.01). Further, the mean number of medicine changes was greater for bimatoprost (0.45) and beta-blockers (0.47) than for latanoprost (0.27) (p=0.0008). The cost of visits and medications was lowest for beta-blockers ($119.3+/-$78.9) and highest for bimatoprost ($163.8+/-$51.2) (p<0.0001).

CONCLUSIONS

Patients were more persistent with latanoprost and demonstrated lower intraocular pressure, fewer visits, and fewer medicine changes when compared to bimatoprost or beta-blocker therapy. In contrast, the beta-blocker group provided lower overall cost.

Le traitement médical initial : bêtabloquants ou prostaglandines ?

With the emergence of prostaglandin analogs, beta-blockers have been challenged as the initial treatment for glaucoma. It should be remembered that their clinical efficacy in reducing intraocular pressure is well established, systemic passage is much lower with delayed-action forms and gel forms, compliance is excellent and all of these therapeutic advantages are provided with a particularly low cost.

Cost of glaucoma in Canada: analyses based on visual field and physician's assessment

PURPOSE

A longitudinal, retrospective study investigated the cost of primary open angle glaucoma (POAG).

METHODS

Patient files from two tertiary care glaucoma practices were reviewed. Patients diagnosed with POAG and >/=2.5 years of follow-up data were included. Data collected included visual field mean deviation, physician's assessment, and resource utilization (physician visits, procedures, and medications). Costs, reported in 2001 Canadian dollars, were compared between groups, based on initial visual field mean deviation, including mild (<5 dB), moderate (5 to <12 dB), and severe (>/=12 dB), and based on physician's assessment, including controlled, uncontrolled, or patients initially uncontrolled for 12 months who become controlled.

RESULTS

Of 411 patient charts extracted, 265 were included; 35 were excluded for ocular comorbidities and 111 patients with insufficient follow-up. Mean (standard deviation) yearly costs overall (N = 265) and for mild (n = 90), moderate (n = 91), and severe (n = 84) groups were $508 ($278), $408 ($266), $512 ($288), and $609 ($243), respectively. Differences between mean yearly costs were statistically significant for all three groups (P < 0.05). Costs for controlled (n = 110), uncontrolled (n = 76), and uncontrolled then controlled group (n = 79) were $423 ($243), $594 ($314), and $542 ($256), respectively. The controlled group cost was significantly lower than both of the other groups (P < 0.05).

DISCUSSION AND CONCLUSIONS

The cost of treating POAG increases with visual field mean deviation severity and uncontrolled disease. Many patients diagnosed with glaucoma had already progressed to later stages in the disease process. Early disease detection may provide a substantial cost savings to the health care system.

Observed time between prescription refills for newer ocular hypotensive agents: the effect of bottle size

PURPOSE

To describe prescription refill patterns of ocular hypotensive therapies and to measure differences among refill rates across bottle sizes.

DESIGN

Retrospective, population-based, cohort study.

METHODS

This study included patients dispensed bimatoprost, brimonidine, dorzolamide/timolol, latanoprost, timolol gel (XE) 0.5%, or travoprost between January 1, 1996, and March 30, 2002. The initial fill date was identified for the cohort-defining ocular hypotensive, and the number of days between each subsequent refill was calculated. The analysis was repeated in patients with at least four refills to evaluate potential bias. Descriptive and survival analyses evaluated differences in refill rates across bottle sizes.

RESULTS

In the 27,387 patients contributing up to four evaluable refill sequences, the amount of drug contained in bottles did not predict the number of days between fills. Patients dispensed larger bottles typically refilled sooner than drop-count studies would predict; results for patients with at least four refills (n = 12,976) confirmed these findings. Survival analysis demonstrated that the bottle size trend held across classes of therapy. Compared with 5.0-ml bottles, patients dispensed 10.0-ml and 15.0-ml bottles returned for refills at approximately 1.5 times the expected rate. When average wholesale prices were applied to refill intervals for selected agents, a 45% excess cost per month was found for the larger bottle sizes (10.0 ml vs 5.0 ml or 5.0 ml vs 2.5 ml).

CONCLUSIONS

Expected refill patterns predicted by bottle size and mean number of drops do not reflect observed refill patterns. Patients dispensed larger bottle sizes return for refills much sooner than expected, regardless of the class of therapy.

Naturalistic, prospective study of glaucoma and ocular hypertension treatment in France: strategies, clinical outcomes, and costs at 1 year

PURPOSE

To prospectively observe second-line treatment strategies, their clinical outcomes, and treatment costs in patients with glaucoma or ocular hypertension (OH) in France.

METHODS

Patients were recruited between 1998 and 2000 in 37 centers and were followed for up to 2 years. Outcomes were numbers of and reasons for treatment changes, changes in clinical parameters (intraocular pressure [IOP] levels, visual field defects, and optic nerve excavation), and direct medical costs associated with glaucoma management in patients receiving monotherapy or combination therapy. This article reports results of an interim analysis of 1-year follow-up data for patients having at least two contacts with a study ophthalmologist.

RESULTS

Data were analyzed for 283 patients and 549 treated eyes. Ocular hypotensive monotherapy was used as first-line therapy in 92.0% of eyes. Second-line treatment was initiated an average of 3.4 +/- 0.5 years after diagnosis, primarily due to insufficient IOP control (62.8%). Mean IOP reductions after 1 year of second-line therapy were 3.0 mmHg in eyes treated with latanoprost monotherapy versus 2. 1 mmHg in those receiving beta-blocker monotherapy (p = 0.02) and 5.4 mmHg in eyes treated with the latanoprost + timolol combination versus 4.1 mmHg in those receiving combination therapies that did not include latanoprost (p = 0.01). Although second-line treatment with latanoprost was more costly than treatment with beta blockers, the average daily cost for latanoprost monotherapy was similar to that for patients who failed beta-blocker monotherapy, and latanoprost + timolol was less costly than therapeutic combinations without latanoprost.

CONCLUSIONS

Insufficient IOP control is the main reason for changing first-line treatment in patients with glaucoma or OH. After 1 year, second-line treatment with latanoprost, as monotherapy or combined with timolol, provides superior IOP control at an acceptable cost.

Medical therapy cost considerations for glaucoma

PURPOSE

To determine the calculated daily patient cost (cost minimization) of medical glaucoma therapy and review cost trends.

DESIGN

Experimental, controlled, prospective study.

METHODS

The actual volume of various glaucoma medications or glaucoma medications with redesigned bottles was determined for most commercially available sizes of the tested products. The drops per milliliter based on the actual volume and the daily costs of the dosage schedules recommended by the manufacturers were compared. The cost of each bottle of medication was determined from the average wholesale price (AWP) in the United States. A comparison to 1999 prices where applicable will be analyzed to review costing trends.

RESULTS

The generic timolol products (range, US dollars 0.38-US dollars 0.46 per day) were similar on a cost per day basis vs Betimol (Santen, Napa Valley, California, USA), Optipranolol (Bausch and Lomb Pharmaceuticals, Tampa, Florida, USA) and Timoptic (Merck, West Point, Pennsylvania, USA). Their percentage cost increase ranged from 5% to 22% since 1999, except for generic timolol XE gel-forming solution (48%). Betagan (Allergan, Irvine, California, USA), Betoptic S (Alcon Laboratories, Fort Worth, Texas, USA), and Ocupress (Novartis, Duluth, Georgia, USA) ranged from US dollars 0.88 to US dollars 1.11 per day, and their percentage cost increase ranged from 33% to 53%. Some brand-only products have raised their AWPs a greater percentage, including Betoptic S (37%), Iopidine (Alcon, Fort Worth, Texas, USA) (50%), Ocupress (Novartis Ophthalmics, Duluth, Georgia, USA) (53%), and Pilopine gel (Alcon, Fort Worth, Texas, USA) (32%). The mean cost per day for the topical carbonic anhydrase inhibitors Azopt (Alcon Laboratories; US dollars 1.33 per day) and Trusopt (Merck; US dollars 1.05 per day) differed from 1999 when prices were almost identical. Cosopt (Merck; timolol 0.5% plus dorzolamide 2%, US dollars 1.04 per day) was less than the cost of separate bottles of a topical carbonic anhydrase inhibitor and a beta-blocker. The selective alpha-2 agonist brimonidine 0.15% with Purite (Alphagan-P, Allergan, 5 ml) twice daily was US dollars 1.29 per day. The prostaglandin analogs were comparably priced with Lumigan (Allergan) US dollars 0.95 per day, Xalatan (Pharmacia and Upjohn, Kalamazoo, Michigan, USA) US dollars 1.25 per day, Travatan (Alcon Laboratories) US dollars 1.01 per day, and Rescula (Novartis) US dollars 0.90 per day.

CONCLUSIONS

All generic timolol, Betimol, Optipranolol, Timoptic, and Timoptic XE (Merck) ranged from US dollars 0.38 to US dollars 0.50 per day. Other beta-blocker products were about twice as costly, ranging from US dollars 0.88 to US dollars 1.11 per day. Cosopt (US dollars 1.05 per day) was less costly than separate bottles of a topical beta-blocker and a topical carbonic anhydrase inhibitor dosed three times daily or twice daily. The prostaglandin analogs ranged from US dollars 0.90 per day (Rescula) to US dollars 1.25 per day (Xalatan). Newer glaucoma medications exhibit similar costs per day in many cases, compared with more traditional medications, especially with greater price increases in older brand-only products.

Cost-minimisation study of dorzolamide versus brinzolamide in the treatment of ocular hypertension and primary open-angle glaucoma: in four European countries

OBJECTIVE

Cost is an issue when prescribing two drugs with equivalent efficacy. We compared the direct medical costs of topical brinzolamide 1% (twice a day or three times daily) with topical dorzolamide 2% (twice a day or three times daily) in France, Italy, Portugal and Spain in patients with ocular hypertension or primary open-angle glaucoma.

DESIGN AND SETTING

Three double-blind, controlled, randomised trials (with a study duration of 3 months) compared the response rate of brinzolamide twice a day or three times daily versus dorzolamide three times daily, and the response rate of brinzolamide-timolol twice a day versus a dorzolamide-timolol combination twice a day. A fourth double-blind randomised trial (with a duration of 12 months) compared brinzolamide twice a day and three times daily with timolol monotherapy. Local tolerance was compared in two dedicated studies. Rates of switching to a new medication regimen were evaluated through a US health maintenance organisation database. In case of treatment failure, the patients were treated with latanoprost. A model was developed to value direct medical costs over 3 months. The economic perspective was that of the third-party payer and the patient, and included direct medical costs (reimbursed part plus co-payment).

PATIENTS

Patients with ocular hypertension and/or primary open-angle glaucoma who had not responded to or could not tolerate beta-blocker therapy.

OUTCOME MEASURE

The daily direct medical costs of therapy with the two drugs.

RESULTS

As monotherapy, brinzolamide twice daily and three times daily was found to be as efficacious as dorzolamide three times a day. Brinzolamide twice daily plus timolol was also as efficacious as a combination of dorzolamide and timolol twice a day. Stinging of the eye upon instillation with brinzolamide was experienced by fewer patients than with dorzolamide (p < 0.0001). The likelihood of patients treated with dorzolamide changing therapy was 1.28 times greater than that for those treated with brinzolamide. The size of the brinzolamide drop is 18.7% smaller than that of dorzolamide allowing seven more therapy days per bottle with brinzolamide twice daily than with dorzolamide monotherapy, and five more days when brinzolamide is used three times a day. The direct medical costs for patients treated with brinzolamide were lower in all four European countries when drop size was taken into account than for those treated with dorzolamide. Sensitivity analyses confirmed the robustness of our findings.

CONCLUSION

Because brinzolamide can be prescribed twice daily in monotherapy and because fewer patients treated with brinzolamide switch therapy due to local intolerance, our model suggests that brinzolamide is a cost-saving alternative to dorzolamide.

Latanoprost versus combined timolol and dorzolamide

We reviewed available data comparing latanoprost and combined timolol and dorzolamide and the additive effect of latanoprost in patients receiving timolol and dorzolamide in combination using a literature search through the electronic Medline database and presentations from proceedings of recent glaucoma meetings. Several studies have shown that the intraocular pressure (IOP)-lowering effect of latanoprost once a day is equivalent to timolol 0.5% twice a day and concomitant or combined dorzolamide 2% twice a day. Adding latanoprost to timolol and dorzolamide leads to a further 16% reduction of IOP. We conclude that the effect on IOP reduction of latanoprost is similar to combined timolol and dorzolamide, and the additive effect of latanoprost to a combination of timolol and dorzolamide is clinically relevant. In most cases, the overall safety profile of latanoprost is better than combined timolol and dorzolamide.

Changing paradigms in the medical treatment of glaucoma

Glaucoma is defined by a typical optic neuropathy accompanied by characteristic visual field loss and eventual blindness. The major risk factor for glaucoma is elevated intraocular pressure (IOP). Lowering IOP is currently the only proven method for reducing the risk of glaucomatous visual field loss and remains the primary goal of therapy. With the recent introduction of many new medications that lower IOP, the definition of what constitutes maximum tolerated medical therapy has been changing. The treatment can now be tailored better to each individual patient. The regimen needs to be affordable, easy to understand, and least interfering with the patient's quality of life. beta-blockers still are the mainstay of initial therapy, but more and more prostaglandin analogs and also alpha-2 agonists are being used initially. Systemic carbonic anhydrase inhibitors and cholinergics are being used less frequently.

Cost analysis of glaucoma medications: a 3-year review

PURPOSE

To evaluate yearly cost of glaucoma medications at a university-affiliated teaching hospital with its own health maintenance organization from 1998 through 2000.

METHODS

We retrieved data from the Scott and White prescription claims file for 1,484 patients concerning Health Plan glaucoma-medication prescriptions for the years 1998 through 2000. Patient inclusion criteria were as follows: 1) use of a single or fixed-combination topical glaucoma medication during all four quarters of at least one full-year, 2) treatment of both eyes, 3) participation in the Health Plan prescription program, and 4) prescriptions filled at pharmacies participating in the Health Plan prescription program.

RESULTS

Over this 3-year period, the most costly medication per patient per year was dorzolamide hydrochloride-timolol maleate (Cosopt; Merck, West Point, PA [$470]), followed by betaxolol hydrochloride (Betoptic-S; Alcon, Fort Worth, TX [$370]), latanoprost (Xalatan; Pharmacia and Upjohn, Kalamazoo, MI [$352]), dorzolamide hydrochloride (Trusopt; Merck, West Point, PA [$288]), brimonidine tartrate (Alphagan; Allergan Pharmaceuticals, Irvine, CA [$273]), brinzolamide (Azopt; Alcon, Fort Worth, TX [$243]), timolol maleate 0.5% in a gel-forming solution (Timoptic-XE 0.5%; Merck, West Point, PA [$190]), carteolol hydrochloride (Ocupress; Otsuka Pharmaceutical, Rockville, MD [$183]), generic levobunolol hydrochloride 0.5% ($138), metipranolol (Optipranolol; Bausch and Lomb Pharmaceuticals, Tampa, FL [$135]), and generic timolol maleate 0.5% ($133).

CONCLUSION

Differences in yearly cost exist among topical glaucoma medications.

Meta-analysis of the effect of latanoprost and brimonidine on intraocular pressure in the treatment of glaucoma

OBJECTIVE

The purpose of this study was to indirectly quantify and compare the intraocular pressure (IOP)-lowering effects of latanoprost and brimonidine eye drops at baseline and after 3 and 6 months in the treatment of primary open-angle glaucoma.

METHODS

This meta-analysis combined data from all randomized controlled trials comparing the effects on IOP of latanoprost and brimonidine treatment in adults with a baseline IOP > or =20 mm Hg. MEDLINE and EMBASE were searched for reports of the ophthalmic administration of either drug versus the other, placebo, or active therapy. Included studies reported IOP as either means or differences (with SD or SE) and sample sizes. A random-effects model was used to pool data within each drug group. As a proxy for success rates, area under the curve (AUC) was calculated for the proportion of patients having an IOP <20 mm Hg.

RESULTS

One hundred fifty-five articles reporting on 158 trials were identified; 147 papers were rejected (141 were not randomized controlled trials, 5 were duplicates, and 1 had nonextractable data), leaving 9 trials from 8 articles. A total of 2152 patients were included in the meta-analysis: 597 received latanoprost, 571 received brimonidine, and the remainder received timolol or betaxolol. Baseline IOPs were similar in patients randomized to latanoprost or brimonidine (25.3 and 24.6 mm Hg, respectively). At 3 months, latanoprost and brimonidine reduced IOP by 8.4 and 6.5 mm Hg, respectively (P = 0.004 latanoprost vs brimonidine), and at 6 months by 8.0 and 6.2 mm Hg, respectively (P = 0.045). AUC was 0.834 and 0.675 at 3 months for latanoprost and brimonidine, respectively, and 0.817 and 0.715 at 6 months, respectively (both, P < 0.001).

CONCLUSIONS

This indirect comparison of data from the available randomized clinical trials showed latanoprost to be statistically superior to brimonidine in reducing IOP in adults with primary open-angle glaucoma. Additional long-term, head-to-head comparisons of the efficacy, safety, and cost of latanoprost and brimonidine are needed to support and supplement these findings.

Emerging perspectives on glaucoma: highlights of a roundtable discussion

PURPOSE

To present emerging perspectives on open-angle glaucoma related to patient compliance, current drug therapy, and treatment options.

METHODS

Roundtable discussion.

RESULTS

The panel discussion identified the following issues about patient compliance:1. It is a common problem in clinical practice and is often underappreciated by physicians.2. It is difficult for clinicians to detect.3. There are several risk factors that increase the probability of noncompliance. 4. Compliance can be improved through education, communication, improvement of the doctor-patient relationship, compliance aids, and simplifying the treatment regimen.

CONCLUSION

Patients' compliance with the therapeutic regimen for open-angle glaucoma is very important to the eventual outcome of their disease treatment. Physicians can improve their patients' compliance by a few simple, cost-effective interventions in the clinical setting. When considering different agents as first-line therapies, once-a-day dosing would be optimal for enhancing compliance.