Glaucoma medication persistence with a fixed combination versus multiple bottles

Understanding the treatment paradigm and the sequencing of antiglaucoma fixed-dose combinations in a tertiary center in South India

PURPOSE

To analyze the medical management of primary open-angle glaucoma (POAG) and ocular hypertension (OHT) and the placement of fixed-drug combination drugs (FDC) in the treatment paradigm at a tertiary eye care center in South India.

METHODS

Retrospective study (January 2011-December 2015) of newly diagnosed POAG and OHT patients (≥18 years) with ≥5 years follow-up. Primary outcome included percentage use of different antiglaucoma drugs (at initiation) and FDCs at the first, second, and third progression (sequencing). Secondary outcomes: Percentage discontinuation for different FDCs, efficacy parameters (decrease in intraocular pressure (IOP)/visual field), adverse events, and the median number of antiglaucoma medications (AGMs) after 5 years.

RESULTS

Three hundred and seventy eyes (198 patients) were analyzed; 84% of them had POAG. Prostaglandin analogs (PGAs) were the most common (66.2%). FDCs were started in 48 eyes (12.9%), with brimonidine + timolol combination being the most common. FDC usage at subsequent modifications was 10.1%, 24.04%, and 30.0%. Beta-blockers and PGAs were the most frequently prescribed AGMs in our practice pattern, with β-blockers being the most consistent one.

CONCLUSION

This study is a fairly large study with a minimum of a 5-year follow-up of patients with POAG and OHT and gives insights into the treatment patterns, use of FDCs, and the need for multiple medications over time.

Canaloplasty and trabeculotomy with the OMNI® surgical system in OAG with prior trabecular microbypass stenting

Purpose

Evaluate effectiveness and safety outcomes for patients treated with canaloplasty and trabeculotomy previously treated with a trabecular microbypass stent (TBS).

Methods

Retrospective, multicenter, IRB approved study. Patients treated with TBS (iStent/iStent inject, Glaukos) and subsequently with OMNI surgical system (OSS) (Sight Sciences). From 5 practices in 5 US states. Open-angle glaucoma (OAG), minimum 3 months follow-up after OSS surgery, Pre-OSS IOP ≥ 17 mmHg on ≥ 1 medication. No glaucoma procedures between TBS and OSS. Endpoints: proportion with ≥ 20% reduction in IOP, IOP between 6 and 18 mmHg, mean IOP, change in IOP, mean number of medications. Adverse events and secondary surgical interventions (SSI). Mann–Whitney rank sum test compared pre-OSS IOP and medications with follow-up.

Results

Twenty seven patients. Average age (SD) 72.2 (10.8), 22/27 primary OAG (82%), mean MD − 6.2 (7.0) dB. Mean IOP before OSS 22.3 (4.3) mmHg on 2.2 (1.3) medications. At last follow-up (mean 11 months) IOP was 17.2 mmHg on 1.8 medications, − 5.1 mmHg (− 23%, p < .001), − 0.4 meds (− 18%, p = .193); ≥ 20% IOP reduction (41%), IOP ≤ 18 (56%). Adverse events were non-serious. Hyphema > 1 mm (3, 11%), BCVA decrease (4, 15%), IOP spike (2, 7%). SSI (4, 15%) had higher pre-OSS IOP (23.4 mmHg) and worse MD (− 9.6 dB).

Conclusion

Patients uncontrolled by medication and a prior TBS would once have been candidates for trabeculectomy and tube shunts. OSS offered a minimally invasive option that provided IOP control and avoidance of traditional surgery for the majority over follow-up averaging 11 months and up to 42 months.

The Efficacy, Safety and Satisfaction Associated with Switching from Brinzolamide 1% and Brimonidine 0.1% to a Fixed Combination of Brinzolamide 1% and Brimonidine 0.1% in Glaucoma Patients

We evaluated glaucoma patients for the efficacy, safety and satisfaction associated with switching from brinzolamide 1% and brimonidine 0.1% to a fixed combination of brinzolamide 1% and brimonidine 0.1%. A total of 22 glaucoma patients were enrolled and completed this prospective, nonrandomized study that evaluated patients who underwent treatment with at least brinzolamide 1% and brimonidine 0.1%. Patients on brinzolamide 1% and brimonidine 0.1% were switched to a brinzolamide/brimonidine fixed-combination ophthalmic suspension (BBFC). Evaluations of intraocular pressure (IOP), superficial punctate keratopathy (SPK) and conjunctival hyperemia were conducted at baseline and at 4 and 12 weeks. The Treatment Satisfaction Questionnaire for Medication-9 (TSQM-9) was utilized to assess the change in treatment satisfaction. At baseline and at 4 and 12 weeks, the IOP was 15.0 ± 4.1, 14.8 ± 4.1 and 14.8 ± 4.1 mmHg, respectively. There were no significant differences observed at any of the time points. However, the SPK score significantly decreased at 12 weeks, even though no significant differences were observed for the conjunctival hyperemia incidence at any of the time points. After switching from brinzolamide 1% and brimonidine 0.1% to BBFC, there was a significant increase in the TSQM-9 score for convenience and global satisfaction. Both an improvement in the degree of SPK and an increase in treatment satisfaction occurred after switching from brinzolamide 1% and brimonidine 0.1% to BBFC, even though there were sustained IOP values throughout the 12-week evaluation period.

Brinzolamide/brimonidine fixed-dose combination bid as an adjunct to a prostaglandin analog for open-angle glaucoma/ocular hypertension

PURPOSE

To evaluate the additive intraocular pressure-lowering effect of twice-daily brinzolamide 1%/brimonidine 0.2% fixed-dose combination (BBFC) as an adjunct to a prostaglandin analog (PGA) in patients with open-angle glaucoma or ocular hypertension insufficiently controlled with PGA monotherapy.

METHODS

In this Phase 4, double-masked trial, patients aged ⩾18 years, with a mean intraocular pressure of ⩾19 and <32 mm Hg in at least one eye were randomized (1:1) to receive BBFC + PGA (n = 96) or vehicle + PGA (n = 92) for 6 weeks. The primary endpoint was the mean change in diurnal intraocular pressure from baseline (averaged over 09:00 and 11:00 h) at Week 6.

RESULTS

The mean diurnal intraocular pressure at baseline was similar in the BBFC + PGA (22.8 mm Hg) and vehicle + PGA (22.9 mm Hg) groups. The least squares mean change in diurnal intraocular pressure from baseline at Week 6 was greater with BBFC + PGA (-5.59 mm Hg (95% confidence interval: -6.2 to -5.0)) than with vehicle + PGA (-2.15 mm Hg (95% confidence interval: -2.7 to -1.6)); the treatment difference was statistically significant in favor of BBFC + PGA (-3.44 mm Hg, (95% confidence interval: -4.2 to -2.7); p < 0.001). Ocular adverse events were reported in 21.1% and 8.7% of patients in the BBFC + PGA and vehicle + PGA groups, respectively. The most frequent ocular adverse event was ocular hyperemia (5.3%) in the BBFC + PGA group and blurred vision (2.2%) in the vehicle + PGA group.

CONCLUSION

BBFC + PGA significantly reduced mean diurnal intraocular pressure than PGA alone in patients with open-angle glaucoma or ocular hypertension. The safety findings with BBFC + PGA were consistent with the known safety profile of the individual medications.

A comparative study on the efficacy of brinzolamide/timolol versus brinzolamide/brimonidine fixed drug combinations in primary open-angle glaucoma

Background

To compare the efficacy of brinzolamide 1%/timolol 0.5% fixed drug combination (BTFC) with brinzolamide 1%/brimonidine 0.2% fixed drug combination (BBFC) among the patients with primary open-angle glaucoma (POAG).

Results

The treatment with BTFC in the Group A subjects showed a significant decrease in the intraocular pressure (p = 0.0355*) and a significant increase in the central corneal thickness (p = 0.0087*). Similarly, in the Group B subjects, the treatment with BBFC showed a significant decrease in the intraocular pressure (p = 0.0327*) and a significant increase in the central corneal thickness (p = 0.0227*). In the process of comparing both the fixed drug combinations, there was no significant difference observed in the aspect of efficacy between both the groups in the decrease of intraocular pressure (p = 0.7100) and in the increase of central corneal thickness (p = 0.4077).

Conclusion

Both the fixed drug combinations almost showed a similar efficacy in treating the respective groups, and there is no significant difference observed in the aspect of efficacy between both the fixed drug combinations in decreasing the intraocular pressure and in increasing the central corneal thickness.

Ocular and systemic pharmacokinetics of brimonidine and brinzolamide after topical administration in rabbits: comparison between fixed-combination and single-drug formulations

AIM

The aim of this study was to compare the ocular and systemic absorption of brimonidine (BMD) and brinzolamide (BZM) in rabbits after the topical administration of a fixed-combination ophthalmic suspension of 0.1% BMD tartrate and 1% BZM (FCBB) with that after the administration of the respective single-drug formulations.

MATERIALS AND METHODS

Ocular and systemic drug absorption was estimated by determining BMD and BZM concentrations in the aqueous humor, retina/choroid, vitreous body, and blood/plasma by liquid chromatography/tandem mass spectrometry after the administration of FCBB, 0.1% BMD tartrate ophthalmic solution (0.1% BMD), or 1% BZM ophthalmic suspension (1% BZM) to rabbits.

RESULTS

In concomitant administration, instilling 0.1% BMD and 1% BZM successively without interval lowered aqueous humor concentrations of both drugs compared to those observed with a 5-min interval. After FCBB administration, BMD and BZM concentrations in the aqueous humor were comparable with those observed after the administration of 0.1% BMD and 1% BZM, whereas BMD concentrations in posterior ocular tissues were equal to or higher than those observed after 0.1% BMD. Plasma BMD concentrations following the administration of FCBB were 0.8-fold lower than those after 0.1% BMD; no remarkable differences were observed in blood BZM concentrations for both formulations.

CONCLUSIONS

FCBB achieved drug distribution in the aqueous humor and systemic exposure that were comparable to those for the single-drug formulations. The viscosity of FCBB may increase BMD distribution in the retina/choroid. The administration interval affects ocular drug absorption with the concomitant administration of 0.1% BMD and 1% BZM, which can be overcome by using the fixed-combination of both drugs.

Current and new pharmacotherapeutic approaches for glaucoma

INTRODUCTION

Glaucoma is the leading cause of irreversible blindness worldwide. Medical therapy is the main line of treatment of open-angle glaucoma (OAG) and ocular hypertension. Despite the expansion of the glaucoma lineup with the newly approved medication classes, many barriers and issues still exist with topical therapy. Novel non-topical drug delivery may address such issues, adding more options to glaucoma pharmacotherapy.

AREAS COVERED

This review outlines current topical therapies for glaucoma, in addition to new medications under trials. The issues with topical therapy, in general, are discussed, as well as the new non-topical drug delivery systems. The authors performed a comprehensive search for published studies on glaucoma medical therapy using the electronic database of PubMed and manual search for each medication and non-topical delivery options. The extra- and intraocular delivery methods and the new topical glaucoma medications under research are covered.

EXPERT OPINION

Medical management of glaucoma represents a challenge for both patients and clinicians. Noncompliance (e.g. difficulty with administering the eye drops), cost, side effects, and intraocular pressure fluctuation are the major problems with topical therapy. To overcome such barriers, research should continue in developing new medications and innovation of non-topical drug delivery systems.

Persistence and treatment patterns of fixed combination drugs for glaucoma: a retrospective claims database study in Japan

Background

Poor persistence with glaucoma therapy can lead to disease progression and subsequent blindness. Persistence with second-line glaucoma combination treatment in a Japanese real-world setting and whether it differed from fixed and unfixed combination drugs was investigated.

Methods

This was a retrospective, non-interventional, cohort study using data from a Japanese medical claims database. Patients with glaucoma aged ≥20 years with a first drug claim for glaucoma treatment between 01 July 2005 and 30 October 2014 and with data for > 6 months before and after this first prescription were included. The primary endpoint was duration of drug persistence among glaucoma patients with and without the use of fixed combination drugs in the year following initiation of second-line combination treatment.

Results

Of 1403 patients included in the analysis, 364 (25.94%) received fixed combination drugs and 1039 (74.06%) received unfixed combination drugs as second-line treatment. Baseline characteristics were generally comparable between the groups. A total of 39.01% of patients on fixed combination drugs, compared with 41.67% of patients on unfixed combination drugs, persisted on their glaucoma drugs 12 months post second-index date. Median persistence durations for the fixed combination drugs and unfixed combination drugs groups were 6 (95% confidence interval [CI]: 5–8) and 7 months (95% CI 6–9), respectively. Patients who received prostaglandin analogs (PGAs) were the most persistent with their treatment (n = 99, 12.84%). Patients diagnosed with primary open-angle glaucoma were less likely to experience treatment modification (hazard ratio [HR]: 0.800, 95% CI 0.649–0.986, P = 0.036), while those diagnosed with secondary glaucoma were more likely to experience treatment modification (HR: 1.678, 95% CI 1.231–2.288, P = 0.001) compared with glaucoma suspects.

Conclusions

In this retrospective claims database study, the persistence rate of second-line glaucoma combination treatment was low, with no difference in persistence between glaucoma patients receiving unfixed combination drugs compared with fixed combination drugs. Patients on PGA showed greater persistence rates compared with other treatments.

Fixed-combination topical anti-hypertensive ophthalmic agents

INTRODUCTION

Fixed-combination glaucoma medications have altered the paradigm of ocular hypertension and glaucoma treatment and are in widespread use today. A comprehensive review of fixed-combination medications will help educate and inform providers for optimal patient care.

AREAS COVERED

In this review, the authors describe the composition, mechanism of action, efficacy, side effects, and safety profile of fixed-combination agents for the treatment of ocular hypertension and glaucoma as well as comparisons between the most frequently prescribed medications.

EXPERT OPINION

Fixed-combination therapeutics provide an effective and efficient means of lowering intraocular pressure with comparable side effects and outcomes to constituent parts with lower patient exposure to preservatives and improvement in compliance.

[Primary open-angle glaucoma]

Primary open-angle glaucoma is a progressive chronic optic neuropathy, typically bilateral, that occurs after the age of 40 years. It is the second leading cause of irreversible blindness in the world. Primary open-angle glaucoma corresponds to a progressive loss of retinal ganglion cell characterized by an excavation of the optic disc associated with typical visual field defects. Elevated intraocular pressure is the main risk factor of primary open-angle glaucoma. Diagnosis and monitoring of primary open-angle glaucoma arebased on both analysis of structural alteration, by clinical examination of optic disc completed by imaging tests (Ocular Coherence Tomography), and functional alterations, by visual field tests. The only effective treatment to slow primary open-angle glaucoma progression is the reduction of the intraocular pressure with anti-glaucomatous eye drops, laser or surgical treatments.

Brinzolamide/Brimonidine Fixed Combination: Simplifying Glaucoma Treatment Regimens

INTRODUCTION

To simplify the medical treatment of glaucoma for patients on multiple drops by introducing brinzolamide/brimonidine tartrate fixed combination (BBFC) ophthalmic suspension 1%/0.2% (SIMBRINZA®; Alcon Laboratories, Inc., Fort Worth, TX, USA) to the drop regimen and to establish its efficacy. To demonstrate that fixed combination (FC) therapies are associated with improvements in treatment adherence and persistence with reduced exposure to preservative-related ocular surface problems.

METHODS

Retrospective study: 76 patients were identified as taking BBFC following a switch in treatment regimen. Intraocular pressure (IOP) prior to and 2-17.5 months (average 5.4 months) after the introduction of BBFC was measured. The change in the average number of bottles used per eye was recorded. The rate of adverse effects (AEs) of BBFC was recorded. A two-tailed paired sample t test was used to compare IOP prior to and after the introduction of BBFC for each eye.

RESULTS

Mean change in IOP after BBFC introduction BBFC: - 2.76 mmHg (p < 0.0001). BBFC intolerance: 13%. On average there was a 0.24 reduction in the number of bottles of IOP-lowering medication used per eye (p < 0.0064).

CONCLUSION

A switch to BBFC in the drop regimen is associated with a significant drop in IOP with reduced drop burden. Instead of a third IOP-lowering medication and bottle, a practitioner should consider using BBFC + prostaglandin analogue/FC drop for effective IOP control, reduced drop burden, reduced preservative load and increased likelihood of adherence. This study promotes the concept that any treatment should principally be assessed from the patients' perspective and quality of life.

[The role of fixed dose combinations in the treatment of primary open-angle glaucoma]

A great number of patients with primary open-angle glaucoma require combination therapy with several hypotensive drugs of different pharmacological groups to efficiently compensate the intraocular pressure (IOP) and prevent further development of glaucoma. Although glaucoma treatment usually starts with monotherapy, several preparations administered simultaneously have stronger hypotensive effect further increased by their additive action. However, the increased frequency of instillations may lead to drug washout and decreased patient compliance. Fixed dose combinations (FDCs) are a pharmacological form of eye drops that combines two or more active drugs in a single dosage form. The frequency of FDCs administration does not exceed two per day, which is convenient for long-term application and helps improve patient compliance. FDCs tolerability tends to be higher than that of simultaneous instillations of separate monotherapy drugs, while the hypotensive in clinical trials is comparable, in some real practice trials is superior. A review of existing studies showed that FDCs are superior to monotherapy in terms of cost-effectiveness. The use of FDCs was found to be beneficial for glaucoma treatment from the viewpoints of both reaching the target IOP for preserving visual functions in glaucoma patients, and minimizing the long-term treatment costs.

The Efficacy and Safety of the Fixed Combination of Brinzolamide 1% and Brimonidine 0.2% in Normal Tension Glaucoma: An 18-Month Retrospective Study

PURPOSE

To evaluate efficacy and safety of brinzolamide (1%)/brimonidine (0.2%) fixed combination (BBFC) in normal tension glaucoma (NTG).

METHODS

This retrospective study included NTG patients treated with BBFC as their primary therapy, NTG patients who had changed their medication to BBFC from brinzolamide or brimonidine, and NTG patients who had changed their medication to BBFC from concomitantly using brinzolamide and brimonidine. The intraocular pressure (IOP), mean deviation value, and adverse drug reactions were evaluated.

RESULTS

In the BBFC primary therapy group, the baseline IOP was 17.1 ± 1.4 mmHg, and the mean IOP at 18 months after using BBFC was 12.4 ± 1.8 mmHg. In the brinzolamide monotherapy group, the baseline IOP was 16.2 ± 1.4 mmHg, the mean IOP using brinzolamide was 13.4 ± 1.6 mmHg, and the mean IOP at 18 months after changing to BBFC was 12.3 ± 1.4 mmHg. In the brimonidine monotherapy group, the baseline IOP was 16.5 ± 1.5 mmHg, the mean IOP using brimonidine was 13.3 ± 1.6 mmHg, and the mean IOP at 18 months after changing to BBFC was 12.4 ± 1.4 mmHg. In the unfixed brinzolamide and brimonidine group, the baseline IOP was 17.5 ± 1.3 mmHg, the mean IOP when using unfixed brinzolamide and brimonidine was 12.4 ± 1.4 mmHg, and the mean IOP at 18 months after changing to BBFC was 12.6 ± 1.5 mmHg. There were no serious adverse drug reactions.

CONCLUSIONS

BBFC provides a significant IOP reduction and is a safe antiglaucoma medication for NTG patients.

A Masked, Randomized, Phase 3 Comparison of Triple Fixed-Combination Bimatoprost/Brimonidine/Timolol versus Fixed-Combination Brimonidine/Timolol for Lowering Intraocular Pressure

OBJECTIVE

To evaluate the efficacy and safety of triple fixed-combination bimatoprost 0.01%/brimonidine 0.15%/timolol 0.5% (TFC) versus dual fixed-combination brimonidine 0.2%/timolol 0.5% (DFC) in primary open-angle glaucoma and ocular hypertension.

METHODS

Patients with intraocular pressure (IOP) ≥23 and ≤34 mmHg were randomized to twice-daily TFC or DFC. The primary variable is the change in worse eye mean IOP from baseline at week 12 (modified intent-to-treat (mITT) population). Secondary endpoints are mean IOP and mean change from baseline at weeks 1, 2, 4, 8, and 12 (mITT population). TFC superiority was demonstrated if the primary variable favored TFC (p ≤ 0.05). Sensitivity analyses were conducted, and safety was assessed at all visits.

RESULTS

TFC (n = 93) provided greater IOP reductions from baseline than DFC (n = 97) at week 12 (treatment difference, 0.85 mmHg; p = 0.028) and all other visits. TFC was also superior to DFC in patients with high baseline IOP (i.e., IOP ≥ 25 mmHg; p ≤ 0.011). Conjunctival hyperemia, ocular irritation, and dry eye were reported more often with TFC (p ≤ 0.016); however, discontinuations for ocular adverse events were similar between treatments.

CONCLUSIONS

TFC demonstrated IOP-lowering benefits that outweigh the risk of predominantly mild ocular side effects, which may be particularly relevant in patients who require greater IOP lowering to prevent/delay disease progression. This trial is registered with ClinicalTrials.gov registry number: NCT01241240.

Preservative-free fixed combination of tafluprost 0.0015% and timolol 0.5% in patients with open-angle glaucoma and ocular hypertension: results of an open-label observational study

Background

Efficacy, tolerability and safety of the novel preservative-free fixed combination of tafluprost 0.0015%/timolol 0.5% (Taptiqom^®) were investigated in an observational study in Germany.

Objective

To assess efficacy, tolerability and safety of the preservative-free fixed combination of tafluprost 0.0015%/timolol 0.5% in a real-life setting.

Methods

Intraocular pressure (IOP) was recorded for each eye at baseline (any previous therapy or untreated) and 4–16 weeks after changing medical treatment to or initiating treatment with the preservative-free fixed combination of tafluprost 0.0015%/timolol 0.5%. Change in IOP was evaluated over the study period for all patients and for specific pretreatment subgroups. Clinical signs such as conjunctival hyperemia and lid-parallel conjunctival folds (LIPCOF) were recorded using standardized comparative photographs. Corneal staining, subjective symptoms and local comfort were measured using a four-step scale. All adverse events were recorded.

Results

Among 1,157 patients enrolled, 1,075 patients were treated with the preservative-free fixed combination as the only medication at the final visit. Medical treatment was initiated in 741 patients because of an insufficient IOP-lowering effect of the prior medication. In 343 patients, medication was changed because of tolerability issues. The preservative-free fixed combination lowered IOP significantly in the subgroup of naïve patients, all subgroups with prior monotherapy and patients with prior fixed combinations: naïve patients: −8.9 mmHg, alpha- 2-agonists: −6.4 mmHg, beta-blockers: −5.7 mmHg, carbonic anhydrase inhibitors: −5.2 mmHg, prostaglandins: −4.7 mmHg, fixed-combination prostaglandins/timolol: −2.4 mmHg. At the final visit, clinical signs and subjective symptoms were improved in patients with prior medical therapy. Local comfort was rated as “very good” or “good” by 89.1% of patients at the final visit. Only few adverse events occurred during the treatment period.

Conclusion

The preservative-free fixed combination of tafluprost 0.0015%/timolol 0.5% was effective, well tolerated and showed a good safety profile.

Adherence to Fixed-Combination Versus Unfixed Travoprost 0.004%/Timolol 0.5% for Glaucoma or Ocular Hypertension: A Randomized Trial

PURPOSE

To assess adherence to treatment with fixed-combination travoprost 0.004%/timolol 0.5% (TTFC) compared with separate containers of travoprost 0.004% and timolol 0.5% (TRAV+TIM; unfixed) using electronic dosing aids.

DESIGN

Randomized, controlled, observer-masked clinical trial.

METHODS

setting: Two US clinical sites.

PATIENT POPULATION

Eligible patients were adults diagnosed with open-angle glaucoma or ocular hypertension. Patients (n = 81) were sequentially randomized 1:1 to receive TTFC or TRAV+TIM for 12 months.

INTERVENTION

TTFC was administered once daily in the morning or evening with a single dosing aid. Patients randomized to TRAV+TIM administered TRAV once daily in the evening and TIM once daily in the morning using separate dosing aids.

MAIN OUTCOME MEASURE

Adherence with administered medication, as recorded by the dosing aids.

RESULTS

Mean ± SD patient age was 60 ± 10 years; most patients were male and white. Compared with TRAV+TIM (n = 40), patients receiving TTFC (n = 41) were consistently adherent on a greater percentage of days through month 12 (60% vs 43%). At months 1, 3, 6, and 12, 80% adherence was achieved by 71% vs 38%, 53% vs 30%, 45% vs 16%, and 32% vs 11% of patients receiving TTFC vs TRAV+TIM, respectively. Significantly more patients were adherent on ≥80% of days with TTFC compared with TRAV+TIM (P < .001 to P = .041). Both treatments reduced IOP from baseline, and no safety issues were identified in either group. Ocular hyperemia was the most common treatment-related adverse event (n = 3/group).

CONCLUSIONS

Patients receiving TTFC maintained better treatment adherence compared with patients receiving TRAV+TIM through 12 months of on-therapy evaluation. This suggests that, for patients requiring multiple IOP-lowering medications, a fixed combination may provide improved long-term adherence compared with unfixed therapy.

Randomized, Controlled, Phase 3 Trials of Carteolol/Latanoprost Fixed Combination in Primary Open-Angle Glaucoma or Ocular Hypertension

PURPOSE

To assess the intraocular pressure (IOP)-lowering effects and safety of a carteolol/latanoprost fixed combination drug (OPC-1085EL) vs latanoprost (Study 1) and carteolol (Study 2) in patients with primary open-angle glaucoma (POAG) or ocular hypertension (OH).

DESIGN

Multicenter, randomized, evaluator-masked (Study 1)/double-masked (Study 2), parallel-group studies.

METHODS

Setting: Twenty-eight clinical sites (Study 1) and 19 clinical sites (Study 2) in Japan.

STUDY POPULATION

Outpatients with bilateral POAG or OH whose predose IOP was 18 to <35 mm Hg in the study eye after 4 weeks' treatment with latanoprost (Study 1) or carteolol (Study 2) (defined as baseline).

INTERVENTION

In Study 1, 237 patients applied OPC-1085EL (n = 118) or latanoprost (n = 119) for 8 weeks. In Study 2, 193 patients applied OPC-1085EL (n = 78), carteolol (n = 78), or carteolol/latanoprost concomitant therapy (n = 37) for 8 weeks.

MAIN OUTCOME MEASURE

Adjusted mean IOP reduction at predose from baseline to week 8.

RESULTS

In Study 1, the adjusted mean IOP reductions (95% confidence interval [CI]) were 2.9 (2.5-3.3) mm Hg and 1.6 (1.2-2.0) mm Hg in the OPC-1085EL and latanoprost groups, respectively (P < .0001). In Study 2, the adjusted mean IOP reductions (95% CI) were 3.5 (3.1-3.9) mm Hg and 1.6 (1.2-2.0) mm Hg in the OPC-1085EL and carteolol groups, respectively (P < .0001). All adverse drug reactions of OPC-1085EL observed in both studies were mild in severity and only 1 patient in each study discontinued because of an adverse drug reaction.

CONCLUSIONS

OPC-1085EL is superior to latanoprost or carteolol alone in terms of lowering IOP, and was well tolerated.

Efficacy and tolerability of brinzolamide/brimonidine suspension and prostaglandin analogs in patients previously treated with dorzolamide/timolol solution and prostaglandin analogs

OBJECTIVE

Fixed combination glaucoma medication is increasingly used in glaucoma treatment. There is a lack of comparative study in the literature of non-beta blocker combination agents used adjunctively with a glaucoma agent in a different class. The objective of this study is to evaluate the effect of intraocular pressure (IOP) control and tolerability of non-beta blocker combination suspension with prostaglandin analogs (PGA) in patients with open angle glaucoma who were previously treated with beta blocker combination solution with PGA.

DESIGN

Open-label retrospective review of patient records.

PATIENTS AND METHODS

This study looked at patients with open angle glaucoma taking dorzolamide/timolol solution with PGA that were switched to brinzolamide/brimonidine combination suspension with PGA. This study reviewed the charts of all patients who were at least 21 years old with a clinical diagnosis of open-angle glaucoma or ocular hypertension in at least one eye. Patients needed to have been treated with concomitant use of PGA and dorzolamide/timolol solution for at least one month. Patients using dorzolamide/timolol solution plus PGA with medication related ocular irritation were switched to brinzolamide/brimonidine suspension with the same PGA. Best-corrected visual acuity, ocular hyperemia grading, slit lamp biomicroscopy and Goldmann applanation tonometry measurements, and patient medication preferences were assessed at baseline, 1 month and 3 months.

RESULTS

Forty eyes with open angle glaucoma. The mean age of the patients was 68 and 60% were females. The IOP before the switch was 17.2 and 16.5 (P=0.70) following the switch at 3 months. We found a decreasing trend of ocular hyperemia (P=0.064) and strong preference (P=0.011) for non-beta blocker combination suspension but no difference of visual acuity and slit lamp findings.

CONCLUSION

Brinzolamide/brimonidine combination suspension when used adjunctively with PGA is equally effective. Patients in this study reported greatly reduced ocular redness and shorter duration of stinging with non-beta blocker combination suspension. Their preference of it over dorzolamide/timolol combination solution makes it a viable treatment option, particularly for the aging glaucoma patient with comorbidities that restrict the beta blocker use.

Clinical effectiveness of brinzolamide 1%-brimonidine 0.2% fixed combination for primary open-angle glaucoma and ocular hypertension

The main first-line treatment strategy for glaucoma is to reduce intraocular pressure (IOP) by topical ocular hypotensive medications, but many patients require multiple medications for adequate IOP control. Fixed-combination therapies provide several benefits, including simplified treatment regimens, theoretical improved treatment adherence, elimination of the potential for washout of the first drug by the second, and the reduction in ocular exposure to preservatives. β-Adrenoceptor antagonists (particularly 0.5% timolol) are the most commonly used agents in combination with other classes of drugs as fixed-combination eyedrops, but they are contraindicated in many patients, owing to local allergy or systemic side effects. A fixed-combination preparation without a β-blocker is therefore warranted. This paper reviews the clinical effectiveness of brinzolamide 1% and brimonidine 0.2% fixed combination (BBFC) for use in patients with primary open-angle glaucoma and ocular hypertension. We searched PubMed and the ClinicalTrials.gov registry, and identified three randomized controlled trials comparing BBFC vs its constituents (brimonidine vs brinzolamide), and one comparing BBFC with unfixed brimonidine and brinzolamide. All of the studies demonstrated mean diurnal IOP to be statistically significantly lower in the BBFC group compared with constituent groups and noninferior to that with the concomitant group using two separate bottles. The safety profile of BBFC was consistent with that of its individual components, the most common ocular adverse events being ocular hyperemia, visual disturbances, and ocular allergic reactions. Common systemic adverse effects included altered taste sensation, oral dryness, fatigue, somnolence, and decreased alertness. BBFC seems to be a promising new fixed combination for use in glaucoma patients. However, long-term effects of BBFC on IOP, treatment adherence, and safety need to be determined.

Efficacy and tolerability of fixed-combination bimatoprost/timolol versus fixed-combination dorzolamide/brimonidine/timolol in patients with primary open-angle glaucoma or ocular hypertension: a multicenter, prospective, crossover study

BACKGROUND

Fixed-combination ocular hypotensives have multiple advantages, but triple-therapy dorzolamide/brimonidine/timolol (dorz/brim/tim) is only available in Latin and South America, and information on its relative efficacy is limited. This study compares the efficacy and tolerability of fixed-combination bimatoprost/timolol (bim/tim) and dorz/brim/tim in Mexican patients with primary open-angle glaucoma or ocular hypertension.

METHODS

In this investigator-masked, crossover study, patients with unmet target intraocular pressure (IOP) on once-daily bim/tim or twice-daily dorz/brim/tim received the opposite medication for 3 months before returning to their pre-baseline medication for 3 months. IOP was evaluated before and after morning instillation at months 2, 3, 5 and 6. Primary endpoints were mean IOP change and Ocular Surface Disease Index© (OSDI) score at each visit. The intent-to-treat population was the a priori analysis population, but due to the number of discontinuations, the per-protocol and intent-to-treat populations were used for the primary efficacy and sensitivity analyses, respectively.

RESULTS

Seventy-eight and 56 patients were included in the intent-to-treat and per-protocol populations, respectively. At month 3, statistically significant IOP reductions from baseline were observed in the bim/tim (P < 0.01) and dorz/brim/tim (P < 0.0001) groups, regardless of assessment time. At month 6, patients returned to bim/tim exhibited no significant IOP increase (regardless of assessment time), but patients returned to dorz/brim/tim exhibited a statistically significant IOP increase (P < 0.001) when assessed before instillation of study treatment. Results were similar in both intent-to-treat and per-protocol analysis populations. In the per-protocol analysis, 70% of patients on bim/tim at month 3 had an IOP <14 mm Hg, which declined to 58% (P = 0.0061) at month 6 (ie, after 3 months of dorz/brim/tim treatment). In patients receiving dorz/brim/tim at month 3, 38% had an IOP <14 mm Hg, which remained comparable after return to bim/tim. OSDI scores and incidence of adverse events were similar in both groups.

CONCLUSIONS

In this first direct comparison of the efficacy of dorz/brim/tim and bim/tim, patients switched from dorz/brim/tim to bim/tim demonstrated improved/lower IOP; when returned to dorz/brim/tim, IOP increased to levels seen at study initiation, suggesting that once-daily bim/tim may have greater IOP-lowering efficacy. Both bim/tim and dorz/brim/tim were well tolerated with minimal ocular surface damage.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01737853 (registered October 9, 2012).

The impact of timolol maleate on the ocular tolerability of fixed-combination glaucoma therapies

Glaucomatous optic atrophy is the second most common cause of blindness worldwide, and lowering intraocular pressure (IOP) is the only proven method to slow or stop the progression of the disease. Approximately 40% of patients with elevated IOP will require more than one medication to obtain a modest 20% reduction in IOP, and as a result, some patients may require two medications, provided in either two separate bottles or in one bottle with the use of fixed-combination therapies. Each therapy has its own unique safety and efficacy profile. Topical beta-blockers have a particularly favorable ocular-tolerability profile, and several studies of fixed-combination medications containing the beta-blocker timolol maleate have shown a lower prevalence of some ocular adverse events for the fixed-combination therapy compared to the non-beta-blocker individual component. In this review, we examined clinical data pertaining to the ocular surface tolerability of fixed-combination medications containing timolol maleate in comparison to the individual components. In particular, preference was given to prospective, randomized, multicenter trials of 3 months in duration or longer that compared a fixed-combination therapy to monotherapy with the individual components. A review of the literature revealed that some fixed-combination therapies can provide a reduced risk of common side effects compared to their individual components, with conjunctival hyperemia and ocular allergy being less frequent in some timolol-containing fixed-combination therapies. This effect appears to be most significant for latanoprost 0.005%, bimatoprost 0.03%, and brimonidine 0.2%.

Combination of brinzolamide and brimonidine for glaucoma and ocular hypertension: critical appraisal and patient focus

Glaucoma is one of the leading causes of blindness and is characterized by optic nerve damage that results in visual field loss. Elevated intraocular pressure (IOP) has been associated with glaucoma progression; thus, IOP-lowering medications are the standard of care for glaucoma. Guidelines suggest monotherapy with IOP-lowering agents such as β-blockers (eg, timolol), prostaglandin analogs, carbonic anhydrase inhibitors (eg, brinzolamide), and α2-receptor agonists (eg, brimonidine). However, monotherapy may provide insufficient IOP reduction in some patients, thereby necessitating the use of multiple IOP-lowering medications. Multidrug regimens may be complex, may increase the risk of preservative-related ocular symptoms, and may potentially reduce overall drug exposure as a consequence of drug washout during closely timed sequential administrations; these difficulties may reduce overall drug efficacy and decrease patient persistence and adherence with multidrug treatment regimens. Fixed-combination medications that provide two IOP-lowering therapies within a single solution are available and may overcome some of these challenges. However, all currently available fixed combinations combine timolol with another IOP-lowering agent, indicating that additional fixed-combination alternatives would be beneficial. To meet this demand, a novel fixed combination of brinzolamide 1% and brimonidine 0.2% (BBFC) has recently been developed. In two randomized, double-masked, multinational clinical trials, BBFC had greater IOP-lowering efficacy than brinzolamide or brimonidine monotherapy after 3 months of treatment in patients with open-angle glaucoma or ocular hypertension. In both studies, the overall safety profile of BBFC was consistent with that of brinzolamide and brimonidine. Comparative studies with BBFC versus other IOP-lowering monotherapy and fixed-combination medications are not available, but the IOP reductions observed with BBFC are similar to or greater than those reported in the literature for other glaucoma treatments; thus, BBFC provides an additional fixed-combination therapeutic option for patients who require further efficacious IOP reduction and improved convenience and tolerability versus concomitant administration of two separate medications.

A combined analysis of five observational studies evaluating the efficacy and tolerability of bimatoprost/timolol fixed combination in patients with primary open-angle glaucoma or ocular hypertension

Objective

The aim of this study was to evaluate the safety and efficacy of a fixed combination of bimatoprost 0.03% and timolol (BTFC) in a clinical setting, in a large sample of patients with primary open-angle glaucoma or ocular hypertension and insufficient intraocular pressure (IOP) lowering on prior therapy.

Methods

Patient data were combined (n = 5556) from five multicenter, observational, non-controlled, open-label studies throughout Europe. Patients were identified from 830 sites in Austria, France, Germany, The Netherlands, and Switzerland. Assessments were made at baseline, 6 weeks (in Austrian, German and Swiss centers), and 12 weeks in all centers.

Results

BTFC lowered mean IOP from baseline by 5.4 mmHg over the 12-week duration of the studies (P < 0.0001). At study entry, 92.9% of patients were receiving another ocular hypotensive medication. In patients with no previous treatment (n = 311), BTFC reduced IOP by −9.1 mmHg, corresponding to a reduction from baseline of 36.4% (P < 0.0001). In patients receiving prior therapy of a prostaglandin analog, a β-blocker, or a fixed combination, BTFC reduced IOP by a further 24.5%, 25.9%, and 21.4%, respectively. The majority of patients (90.3%) reported no adverse events. The most common adverse events were conjunctival hyperemia (3.2%) and eye irritation (2.8%). BTFC was rated as “good” or “very good” by 92.5% of physicians and 88.0% of patients. Most patients (96.3%) were equally or more compliant with BTFC than with their previous treatment.

Conclusion

In routine clinical practice, BTFC achieved consistent IOP lowering in both previously treated and untreated patients with primary open-angle glaucoma or ocular hypertension. BTFC was associated with significant IOP reductions, good tolerability, and good compliance.

Intraocular pressure-lowering combination therapies with prostaglandin analogues

Intraocular pressure (IOP) reduction is currently the only therapeutic approach demonstrated to preserve visual function in patients with glaucoma. The first line of glaucoma treatment consists of topical IOP-lowering medications, usually initiated as monotherapy. A significant proportion of patients require more than one medication to reach a target IOP at which optic nerve damage will not progress. As prostaglandin analogues (PGAs) are the most effective class for reducing IOP, one of the other commonly used classes (β-adrenoceptor antagonist [β-blocker], carbonic anhydrase inhibitor or α(2)-adrenoceptor agonist) is frequently combined with a PGA. In the last decade, the use of fixed combinations containing two medications in a single bottle has steadily increased. Fixed combinations have the potential to simplify the dosing regimen, increase patient adherence, avoid the washout effect of the second drop on the first medication instilled, decrease exposure to preservatives and, sometimes, reduce the cost of treatment. Clinical trials have evaluated PGA-based fixed combinations versus unfixed combinations (individual components administered concomitantly) or versus individual monotherapies; however, any advantage that the fixed combinations may have in terms of IOP-lowering efficacy is still debated. For these reasons, the PGA-based fixed combinations are not approved by regulatory authorities in some countries, such as the US. We review the published studies evaluating the efficacy and tolerability of the IOP-lowering unfixed and fixed combination therapies with PGAs. Regarding unfixed combinations, the review shows that α(2)-adrenergic agonists-PGA and carbonic anhydrase inhibitor-PGA combinations seem to be at least as effective at reducing IOP as the β-blocker-PGA combinations. As for the fixed combinations, the review shows that the three PGA-timolol fixed combinations are more effective than their component medications used separately as monotherapy and are better tolerated than the three respective prostaglandins. The three PGA-timolol fixed combinations are less effective at reducing IOP than the unfixed combinations but are better tolerated. The advantage of the fixed combinations in terms of patient adherence and persistence is supported by a very small number of studies and remains to be more accurately determined. Most studies, but not all, seem to show that PGA-timolol fixed combinations are more effective than other available β-blocker fixed combinations (dorzolamide-timolol fixed combinations) at reducing IOP and are similarly tolerated.

Topical prostaglandin fixed combinations in UK primary care: observational study using data from the health improvement network

PURPOSE

To describe the use of 3 prostaglandin/timolol fixed combinations (FCs) in UK primary care, to summarize characteristics of recipients, and to assess 12-month persistence.

METHODS

This retrospective cohort study included first-time recipients of latanoprost/timolol FC, bimatoprost/timolol FC, or travoprost/timolol FC treated between April 1, 2007, and November 30, 2008, identified in The Health Improvement Network database, a large database of anonymized longitudinal electronic medical records of patients treated in UK primary care. Eligible patients were = 18 years old at the index date (date of first prescription). Persistence, defined as a gap =60 days between consecutive prescriptions, was assessed through 12 months post-index for each cohort (Cox proportional hazards models).

RESULTS

A total of 2,015 patients were included: latanoprost/timolol FC, n = 898 (44.6%); bimatoprost/timolol FC, n = 733 (36.4%); travoprost/timolol FC, n = 384 (19.1%). The mean age was approximately 72 years across cohorts (p = 0.792). Glaucoma was the diagnosis for >90% of patients in each cohort. Twelve-month persistence was similar across treatments: latanoprost/timolol FC: 38.2%; bimatoprost/timolol FC: 38.6%; travoprost/timolol FC: 38.3% (p = 0.985). Mean time to therapy change for nonpersistent patients was also similar: 143.3 ± 89.8, 151.0 ± 87.9, and 151.8 ± 87.7 days, respectively (p = 0.095). Among persistent patients, additional therapy was prescribed for 36.2%, 41.7%, and 41.5% of patients, respectively. Among nonpersistent patients, 64.0%, 70.4%, and 69.2%, respectively, restarted the index therapy.

CONCLUSIONS

The largest proportion of first-time recipients of prostaglandin/beta-blocker FC products treated in UK primary care was prescribed latanoprost/timolol FC. Twelve-month persistence was similar (<40%) across the 3 FCs evaluated.

Balancing efficacy and tolerability of prostaglandin analogues and prostaglandin-timolol fixed combinations in primary open-angle glaucoma

BACKGROUND

Lowering intraocular pressure (IOP) is currently the only therapeutic approach that preserves visual function in primary open-angle glaucoma. In making treatment decisions for first- and second-line therapy, the clinician needs to provide an appropriate balance of efficacy and tolerability. Prostaglandin analogues (PGAs) are frequently used as first-line monotherapy, because of their efficacy and low risk of systemic side effects. Similarly, PGA-based fixed combinations are frequently used in patients who progress or fail to achieve the target IOP.

SCOPE

We have reviewed the literature on the management of primary open-angle glaucoma with PGAs, both as monotherapies and in fixed combinations.

FINDINGS

In the clinical trial and meta-analysis data identified, bimatoprost 0.03% seems to be associated with a greater overall ability to lower IOP compared with latanoprost, travoprost or tafluprost, at the cost of a slightly higher incidence of conjunctival hyperaemia. Studies indicate that patients' adherence to treatment is generally better with PGAs than with many other monotherapies. In patients requiring more than one IOP-lowering agent, fixed combination treatments may provide improved adherence and tolerability benefits compared with concomitant use of individual treatments. Bimatoprost/timolol fixed combination appears to be slightly more efficacious than latanoprost/timolol or travoprost/timolol, and tolerability differences between the fixed combinations appear to be slight, probably because the addition of timolol to the PGA component lessens the associated hyperaemia. Surveys on EU physician attitudes appear largely in line with these clinical data.

CONCLUSION

An appropriate balance between efficacy and tolerability ensures optimum IOP lowering and reduces the risk of non-adherence. PGAs largely fulfil this need as monotherapies and as components of combinations.

Comparative efficacy and safety of the fixed versus unfixed combination of latanoprost and timolol in Chinese patients with open-angle glaucoma or ocular hypertension

BACKGROUND

A noninferiority trial was conducted to evaluate the efficacy of a single evening dose of fixed-combination latanoprost 50 μg/mL and timolol 0.5 mg/mL (Xalacom®; LTFC), in Chinese patients with primary open-angle glaucoma (POAG) or ocular hypertension (OH) who were insufficiently controlled on β-blocker monotherapy or β-blocker-based dual therapy.

METHODS

This 8-week, randomized, open-label, parallel-group, noninferiority study compared once-daily evening dosing of LTFC with the unfixed combination of latanoprost, one drop in the evening, and timolol, one drop in the morning (LTuFC). The primary efficacy endpoint was the mean change from baseline to week 8 in diurnal intraocular pressure (IOP; mean of 8 AM, 10 AM, 2 PM, 4 PM IOPs). LTFC was considered noninferior to LTuFC if the upper limit of the 95% confidence interval (CI) of the difference was < 1.5 mmHg (analysis of covariance).

RESULTS

Baseline characteristics were similar for LTFC (N = 125; POAG, 70%; mean IOP, 25.8 mmHg) and LTuFC (N = 125; POAG, 69%; mean IOP, 26.0 mmHg). Mean diurnal IOP changes from baseline to week 8 were -8.6 mmHg with LTFC and -8.9 mmHg with LTuFC (between-treatment difference: 0.3 mmHg; 95%-CI, -0.3 to 1.0). Both treatments were well tolerated.

CONCLUSIONS

A single evening dose of LTFC was at least as effective as the unfixed combination of latanoprost in the PM and timolol in the AM in reducing IOP in Chinese subjects with POAG or OH whose IOP was insufficiently reduced with β-blocker monotherapy or β-blocker-based dual therapy. LTFC is an effective and well tolerated once-daily treatment for POAG and OH.

Role of fixed combinations in the management of open-angle glaucoma

The first-line option for lowering intraocular pressure (IOP) is a single hypotensive agent, but patients frequently require additional IOP-lowering agents to reach their target pressures. Disadvantages of this multi-therapy approach include washout effect, inconvenience and poor adherence. Fixed combinations (FCs) combine two or more hypotensive agents in a single bottle, providing a convenient once-daily therapy, which tends to improve adherence. FCs generally offer equivalent efficacy to concomitant use of the individual components, with equivalent or superior tolerability. Studies also show that FCs can be more cost effective than nonfixed combinations. In terms of optimizing IOP control, minimizing visual field deterioration, preventing visual disability and minimizing associated healthcare costs, FCs are an important component of glaucoma management.

Objective assessment of compliance and persistence among patients treated for glaucoma and ocular hypertension: a systematic review

PURPOSE

This study summarizes findings from objective assessments of compliance (or adherence) and persistence with ocular hypotensive agents in patients with glaucoma and ocular hypertension.

DESIGN

Systematic literature review.

METHODS

A PubMed and reference list search was conducted across publication years 1970-2010, using these terms and variants: "compliance," the equivalent term "adherence," and "persistence" in patients with these conditions and therapies. Summaries of selected studies were stratified by measurement method (electronic monitor, prescription fills review, medical chart review). Measures of central tendency across studies were calculated for commonly-reported compliance or persistence measures.

RESULTS

Fifty-eight articles met all inclusion/exclusion criteria: measurement of compliance-electronic monitoring (seven studies reported in 14 articles), measurement of compliance/ persistence-prescription records (36 studies in 38 articles), and measurement of persistence- medical chart review (six studies in six articles). From electronic monitoring, most therapy-experienced patients took medication consistently, but ≥20% met criteria for poor compliance. From prescription records, only 56% (range 37%-92%) of the days in the first therapy year could be dosed with the medication supply dispensed over this period. At 12 months from therapy start, only 31% (range 10%-68%) of new therapy users had not discontinued, and 40% (range 14%-67%) had not discontinued or changed the initial therapy. From medical chart review, only 67% (range 62%-78%) of patients remained persistent 12 months after starting therapy.

CONCLUSIONS

Evidence provided by this review suggests that poor compliance and persistence has been and remains a common problem for many glaucoma patients, and is especially problematic for patients new to therapy. The direction of empirical research should shift toward a greater emphasis on understanding of root causes and identification and testing of solutions for this problem.

Use of glaucoma medications: state of the science and directions for observational research

PURPOSE

To summarize observational studies that focus on the use of glaucoma medications and to identify gaps in knowledge to guide future investigation.

DESIGN

Literature study.

METHODS

We searched the electronic databases MEDLINE, EMBASE, and PubMed for English language articles published through December 2009 using the search terms physician's practice patterns, drug prescriptions, pharmaceutical services, medication adherence, ophthalmology, glaucoma, and ophthalmic solutions. We categorized studies by areas of focus and extracted and summarized key features: study population, data sources, and main findings.

RESULTS

We identified 2224 articles by the search. Fifty-five described glaucoma medication use using large databases. Predominant areas of focus were: trends in prescription choices (n = 13); adherence, persistence, or both (n = 31); rational use of medications (n = 9); and policy-related issues (n = 2). Over the last decade, use of β-blockers and miotics has decreased substantially, whereas new agents, particularly prostaglandin analogs, have become more popular. Nonadherence was an issue in more than 25% of patients. A significant proportion of patients with comorbidities, contraindications, or both had received topical β-blockers.

CONCLUSIONS

To date, most studies have focused on adherence to glaucoma medications and changes in treatment choices. Major gaps in knowledge include prescribing patterns by prescriber specialty (ophthalmologists, primary care physicians, and optometrists), medication-related problems, and subsequent adverse health outcomes. Well-designed longitudinal observational studies addressing these gaps are warranted to improve patient safety.

Efficacy, safety and tolerability of combination therapy with timolol and dorzolamide in glaucoma and ocular hypertension

Combination pharmacotherapy has simplified and improved glaucoma medication regimens. This update focuses on the previous and recent studies on efficacy and tolerability profile of dorzolamide–timolol in adult ocular hypertension and open angle glaucoma patients. Dorzolamide–timolol has been shown to be efficacious and well tolerated in clinical trials and the adverse effects reflect those of the individual components.