From dorzolamide 2%/timolol 0.5% to brinzolamide 1%/timolol 0.5% fixed combination: a 6-month, multicenter, open-label tolerability switch study

Fixed versus Unfixed Combination of Topical Latanoprost/Timolol for Glaucoma: An Observational Study Investigating the Level of Adherence and Ocular Surface Health

PURPOSE

To investigate the effect of fixed combination versus concomitant unfixed topical glaucoma treatment on patients' adherence and ocular surface health.

PATIENTS AND METHODS

This is a 6-month, prospective, parallel-group, observational study in patients with ocular hypertension (OHT), primary open-angle glaucoma (POAG), or exfoliation glaucoma (XFG). A total of 142 patients with similar baseline characteristics were enrolled in this study. Seventy-one patients received a Latanoprost 0.005%/Timolol 0.5% fixed combination in the evening, whereas seventy-one patients received the unfixed treatment with Latanoprost 0.005% in the evening and Timolol 0.5% twice daily. The primary outcome was the adherence rate at baseline, and at the 3- and 6-month follow-up visits. The secondary outcomes included the signs of ocular surface disease (OSD) and intraocular pressure (IOP).

RESULTS

The adherence of patients treated with the fixed combination was higher than the unfixed treatment at the 3-month (78.0% vs. 63.0%, p < 0.001) and at the 6-month visits (73.0% vs. 58.5%, p < 0.01). The Break-up Time, Schirmer test, and Van Bijsterveld score were worse in the unfixed group at baseline and all subsequent examinations (p < 0.05 for all comparisons). There were no differences in the mean IOP between groups at baseline, 1-, and 3-month visits. IOP appears higher in the unfixed group at 6 months (16.7 vs. 15.0 mmHg, p < 0.01).

CONCLUSION

The patients with ocular hypertension and primary open-angle glaucoma treated with a fixed combination are significantly more adherent and show a healthier ocular surface than those treated with an unfixed combination. The study provides significant evidence of the benefits of fixed combination treatment.

Topical Medication Therapy for Glaucoma and Ocular Hypertension

Glaucoma is one of the most common causes of blindness, thus seriously affecting people’s health and quality of life. The topical medical therapy is as the first line treatment in the management of glaucoma since it is inexpensive, convenient, effective, and safe. This review summarizes and compares extensive clinical trials on the topical medications for the treatment of glaucoma, including topical monotherapy agents, topical fixed-combination agents, topical non-fixed combination agents, and their composition, mechanism of action, efficacy, and adverse effects, which will provide reference for optimal choice of clinical medication. Fixed-combination therapeutics offer greater efficacy, reliable security, clinical compliance, and tolerance than non-fixed combination agents and monotherapy agents, which will become a prefer option for the treatment of glaucoma. Meanwhile, we also discuss new trends in the field of new fixed combinations of medications, which may better control IOP and treat glaucoma.

Keratitis in six dogs after topical treatment with carbonic anhydrase inhibitors for glaucoma

CASE DESCRIPTION

6 dogs (10 eyes) with keratitis following long-term topical treatment with a carbonic anhydrase inhibitor (CAI) were evaluated. In 4 dogs (6 eyes), CAI treatment was discontinued. Three dogs (4 eyes) underwent enucleation because of end-stage corneal disease. One dog was treated differently in each eye and thus was represented in both aforementioned groups.

CLINICAL FINDINGS

Following initiation of treatment with a CAI (ie, brinzolamide or dorzolamide), the median time to development of severe ocular signs was 266 days (range, 133 to 679 days). Clinically severe ocular signs included ulcerative and nonulcerative perilimbal keratitis or severe diffuse keratitis with marked vascularization. The keratitis was refractory to treatment with anti-inflammatory medications. Histologic and immunohistochemical examination of enucleated globes was performed in 3 affected dogs and in 1 dog with keratitis that recovered. Corneal lesions included 2 distinct inflammatory infiltrates with plasma cells predominating in the anterior stroma and both T cells and neutrophils in the epithelium. Stromal plasma cells and overlying epithelium exhibited strong positive immunoreactivity for IgG.

TREATMENT AND OUTCOME

Topical CAI treatment was discontinued in 4 dogs after a median of 209 days (range, 44 to 433 days), and in these dogs, clinical improvement was evident within 2 to 4 days of CAI treatment cessation. Signs of keratitis resolved in 12 to 25 days in these 4 dogs, and median follow-up time after CAI discontinuation was 25.5 months (range, 6 to 42 months), during which time signs of corneal disease did not recur.

CLINICAL RELEVANCE

On the basis of this small series, presumed topical CAI-associated keratitis in dogs appeared to be an uncommon immune-mediated disease that was not responsive to corticosteroid treatment. Affected patients improved rapidly, but only after discontinuation of CAI treatment. In dogs with glaucoma, clinicians should consider the development of punctate keratopathy and severe diffuse keratitis as potential adverse effects related to topical administration of CAIs, even after previously uneventful long-term use.

Safety and efficacy of switching from dorzolamide 1.0%/timolol maleate 0.5% eye drops to brinzolamide 1.0%/timolol maleate 0.5% eye drops

Purpose

To evaluate the safety and efficacy of switching from dorzolamide 1.0%/timolol maleate 0.5% fixed-combination (DTFC) eye drops to brinzolamide 1.0%/timolol maleate 0.5% fixed-combination (BTFC) eye drops in patients with primary open-angle glaucoma or ocular hypertension.

Methods

A total of 35 eyes of 35 patients with primary open-angle glaucoma or ocular hypertension using DTFC eye drops were included. Participants discontinued DTFC drops and immediately began using BTFC drops. All other eye drops currently being used were continued. Intraocular pressure (IOP) 1 and 3 months after switching medications was compared with baseline IOP. One month after switching medications, participant preference and adherence were evaluated. Adverse reactions were monitored at each study visit.

Results

The IOP was 17.9±2.6 mmHg at baseline and 18.3±4.1 mmHg and 17.8±3.4 mmHg 1 month and 3 months after switching medications, respectively (P=0.633). The frequency of missing a dose was not different before (6.1%) and after (6.1%) switching to BTFC. Significantly fewer participants reported stinging after switching to BTFC (15.2%) than while using DTFC (51.5%, P,0.01). Blurred vision was reported with the same frequency before (39.4%) and after (42.4%) switching to BTFC. A total of 33.3% and 27.3% of patients preferred DTFC and BTFC, respectively. Several patients withdrew from the study because of discomfort (n=2, 5.7%), discharge (n=1, 2.9%), dizziness (n=1, 2.9%), or increased IOP (n=2, 5.7%).

Conclusion

Switching from DTFC to BTFC was well tolerated and did not result in IOP changes or a decreased patient adherence. When glaucoma patients complain of stinging with DTFC administration, switching to BTFC is an acceptable treatment option.

Efficiency, safety, and patient preference of switching from dorzolamide 1%/timolol 0.5% to brinzolamide 1%/timolol 0.5% while maintaining the prostaglandin F2α analog

Background

We investigated the efficiency, safety and patient preference of switching from dorzolamide 1%/timolol 0.5% to brinzolamide 1%/timolol 0.5% while maintaining the prostaglandin F2α analog.

Methods

We initially enrolled 44 eyes from 44 primary open angle glaucoma patients, and a total of 42 patients completed the study. All patients were under treatment with various prostaglandin F2α analogs and dorzolamide 1%/timolol 0.5%. While maintaining the prostaglandin F2α analog, dorzolamide 1%/timolol 0.5% was switched to brinzolamide 1%/timolol 0.5%. Conjunctival hyperemia, superficial punctate keratopathy, and intraocular pressure (IOP) were evaluated at baseline and at 4, 12, and 24 weeks. Adverse events and patient preferences, measured using a questionnaire at study initiation and at 24 weeks, were also noted.

Results

The IOP was 17.7±1.7, 16.8±2.6, 16.7±2.2, and 16.7±2.4 mmHg at baseline and at 4, 12, and 24 weeks, respectively, with no significant differences in IOP values at any time point (P=0.117, one-way analysis of variance). In addition, no significant differences were found in the incidence of conjunctival hyperemia or SPK score at any time point (all P>0.5, by Kruskal–Wallis test). Based on the evaluation of side effects using the questionnaire, stinging/burning was less common (P=0.042), while blurred vision was more common (P=0.003), after switching to brinzolamide 1%/timolol 0.5%. Regarding patient preferences, 13 patients (31%) preferred dorzolamide 1%/timolol 0.5%, 12 patients (29%) preferred brinzolamide 1%/timolol 0.5%, and 17 patients (40%) preferred neither.

Conclusion

When switching from dorzolamide 1%/timolol 0.5% to brinzolamide 1%/timolol 0.5%, the IOP values and incidence of superficial punctate keratopathy and conjunctival hyperemia were sustained throughout the 24-week observation period, and the patient preferences were similar for the two regimens. However, differences were observed in the ocular sensations of stinging/burning with dorzolamide 1%/timolol 0.5% and blurred vision with brinzolamide 1%/timolol 0.5%.

Effect of 3 years of treatment with a dorzolamide/timolol (1%/0.5%) combination on intraocular pressure

Purpose

We aimed to evaluate the effect on the intraocular pressure (IOP) of a dorzolamide/timolol (1%/0.5%) fixed combination (DTFC) ophthalmic agent for 3 years.

Participants

A total of 19 consecutive patients who had previously been treated with mono-therapy or any combination of a beta-blocker, carbonic anhydrase inhibitor, or prostaglandin analog, for primary open-angle glaucoma (POAG) (n=5) or normal tension glaucoma (N=14) were enrolled.

Methods

Patients were switched to DTFC from their prior glaucoma therapy. The IOP was measured at intervals of 4–6 weeks for 3 years. Treatment failure was defined as an increase of IOP by ≥10% from baseline after switching to DTFC.

Results

The average IOP decreased significantly from 14.1±2.9 mmHg at baseline to 12.2±2.2, 11.8±2.4, 12.1±2.5, 11.6±1.8, and 12.1±2.7 mmHg at 3, 6, 12, 24, and 36 months, respectively, after switching therapy (all P<0.05). The mean percent decrease of IOP was 12.0%±13.0%, 14.5%±14.2%, 12.2%±18.7%, 16.0%±12.8%, and 12.8%±15.2% at 3, 6, 12, 24, and 36 months, respectively, after switching. Univariate or multivariate analysis revealed the percent decrease of IOP was associated with the type of glaucoma (POAG) at 3 and 12 months, and with the baseline IOP at 3, 12, 24, and 36 months. Kaplan–Meier analysis demonstrated that the percentage of patients who remained on treatment with DTFC was 94.7%, 94.7%, 84.2%, 78.9%, and 78.9% at 3, 6, 12, 24, and 36 months, respectively. Cox proportional hazards analysis showed that the type of glaucoma (POAG) was associated with an increased risk of failure to control the IOP.

Conclusion

The IOP-lowering effect of DTFC was demonstrated for 3 years in this study. The baseline IOP had an important influence on the reduction of IOP achieved by DTFC.

Effect of dorzolamide/timolol combination on the visual field in glaucoma

PURPOSE

To evaluate the effect of treatment for 3 years with a dorzolamide/timolol (1%/0.5%) fixed combination (DTFC) on visual field progression in patients with open-angle glaucoma.

PARTICIPANTS

A total of 14 consecutive patients were enrolled who had been previously treated with monotherapy or any combination of a beta blocker, carbonic anhydrase inhibitor, and/or prostaglandin analog for primary open-angle glaucoma (POAG; n=4) or normal-tension glaucoma (NTG; n=10).

METHODS

Patients were switched to DTFC from their prior glaucoma therapy. The IOP was measured at intervals of 4-6 weeks, and the visual fields were examined at least twice a year for 3 years. The annual change of mean deviation (MD slope) was used to quantify visual field loss.

RESULTS

The mean MD value was -5.9±5.0 dB at baseline; it was -5.6±4.8 dB at 12 months, -5.9±5.0 dB at 24 months, and -5.6±5.1 dB at 36 months after switching. The mean MD slope was -0.2±0.8 dB/year before switching and 0.3±1.3 dB/year from baseline to 1 year, -0.3±1.1 dB/year from 1-2 years, and 0.3±0.9 dB/year from 2-3 years after switching. The mean MD slope from baseline to 36 months was correlated with the IOP reduction rate at 36 months after switching. Visual field progression was associated with the IOP reduction rate at 12 months after switching.

CONCLUSION

Switching to DTFC from prior glaucoma therapy improved the MD slope for at least 3 years. Reduction of the IOP after switching to DTFC was effective for delaying visual field progression. Although our study was not nonrandomized and was small in scale, the findings suggest that DTFC might have a beneficial effect on the visual fields in patients with open-angle glaucoma.

Interventions for improving adherence to ocular hypotensive therapy

BACKGROUND

Poor adherence to therapy is a significant healthcare issue, particularly in patients with chronic disease such as open-angle glaucoma. Treatment failure may necessitate unwarranted changes of medications, increased healthcare expenditure and risk to the patient if surgical intervention is required. Simplifying eye drop regimes, providing adequate information, teaching drop instillation technique and ongoing support according to the patient need may have a positive effect on improving adherence.

OBJECTIVES

To summarise the effects of interventions for improving adherence to ocular hypotensive therapy in people with ocular hypertension (OHT) or glaucoma.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 6), MEDLINE (June 1946 to June 2012), EMBASE (June 1980 to June 2012), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (June 1937 to June 2012), PsycINFO (1806 to June 2012), PsycEXTRA (1908 to June 2012), Web of Science (1970 to June 2012), ZETOC (1993 to June 2012), OpenGrey (System for Information on Grey Literature in Europe) (www.opengrey.eu/), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 26 June 2012. We did not search the National Research Register (NNR) as this resource has now been now archived. We contacted pharmaceutical manufacturers to request unpublished data and searched conference proceedings for the Association for Research in Vision and Ophthalmology (ARVO), and the Annual Congress for the Royal College of Ophthalmologists (RCO).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that compared interventions to improve adherence to ocular hypotensive therapy for patients with OHT or glaucoma.

DATA COLLECTION AND ANALYSIS

At least two authors independently assessed the search results for eligibility and extracted data for included trials onto specifically designed forms. We did not pool data due to clinical and methodological heterogeneity.

MAIN RESULTS

Sixteen trials (1565 participants) met the inclusion criteria. Seven studies investigated some form of patient education. In six of these studies this education was combined with other behavioural change interventions including tailoring daily routines to promote adherence to eye drops. Eight studies compared different drug regimens (one of these trials also compared open and masked monitoring) and one study investigated a reminder device. The studies were of variable quality and some were at considerable risk of bias; in general, the length of follow-up was short at less than six months with only two studies following up to 12 months. Different interventions and outcomes were reported and so it was not possible to produce an overall estimate of effect. There was some evidence from three studies that education combined with personalised interventions, that is, more complex interventions, improved adherence to ocular hypotensive therapy. There was less information on other outcomes such as persistence and intraocular pressure, and no information on visual field defects, quality of life and cost. There was weak evidence as to whether people on simpler drug regimens were more likely to adhere and persist with their ocular hypotensive therapy. A particular problem was the interpretation of cross-over studies, which in general were not reported correctly. One study investigated a reminder device and monitoring but the study was small and inconclusive.

AUTHORS' CONCLUSIONS

Although complex interventions consisting of patient education combined with personalised behavioural change interventions, including tailoring daily routines to promote adherence to eye drops, may improve adherence to glaucoma medication, overall there is insufficient evidence to recommend a particular intervention. The interventions varied between studies and none of the included studies reported on the cost of the intervention. Simplified drug regimens also could be of benefit but again the current published studies do not provide conclusive evidence. Future studies should follow up for at least one year, and could benefit from standardised outcomes.

Preference for a fixed combination of brinzolamide/timolol versus dorzolamide/timolol among patients with open-angle glaucoma or ocular hypertension

Objective

To assess ocular discomfort upon instillation and patient preference for brinzolamide/timolol relative to dorzolamide/timolol, in patients with open-angle glaucoma or ocular hypertension.

Methods

This was a multicenter, prospective, patient-masked, randomized, crossover study. On day 0, patients received one drop of brinzolamide/timolol in one eye and one drop of dorzolamide/timolol in the contralateral eye. On day 1, patients were randomly assigned to receive one drop of either brinzolamide/timolol or dorzolamide/timolol in both eyes; on day 2, patients received one drop of the alternate treatment in both eyes. Measures included a patient preference question on day 2 (primary) and mean ocular discomfort scale scores on days 1 and 2 (secondary). Safety assessments included adverse events, visual acuity, and slit-lamp examinations.

Results

Of 120 patients who enrolled, 115 completed the study. Of these, 112 patients instilled both medications and expressed a study medication preference on day 2. A significantly greater percentage preferred brinzolamide/timolol to dorzolamide/timolol (67.0% versus 30.4%; P < 0.001). The ocular discomfort (expressed as mean [standard deviation]) with brinzolamide/timolol was significantly lower than with dorzolamide/timolol (day 2:1.9 [2.3] versus 3.7 [2.8], respectively [P = 0.0003]; both days combined: 2.1 [2.5] versus 3.5 [2.9], respectively [P = 0.00014]). On day 1, five patients receiving brinzolamide/timolol reported five nonserious adverse events (AEs): flu (n = 1), bitter taste (n = 2), and headache (n = 2). Four events, bitter taste (two events) and headache (two events), were considered related to brinzolamide/timolol. Events were mild in intensity, except bitter taste of moderate intensity reported by one patient. No AEs were reported at day 2. All AEs resolved without additional treatment. No clinically relevant changes from baseline were observed in best-corrected visual acuity or slit-lamp examinations of ocular signs.

Conclusion

Patients had less discomfort with brinzolamide/timolol than with dorzolamide/timolol, and more expressed a preference for brinzolamide/timolol. Both treatments were generally safe and well tolerated.

Short-term effect of topical brinzolamide-timolol fixed combination on ocular surface of glaucoma patients

AIM

To evaluate the short-term effect of the fixed combination of brinzolamide-timolol on the ocular surface in glaucoma patients.

METHODS

This is a prospective study of 23 eyes of 23 patients with newly diagnosed glaucoma. Schirmer I test, tear break-up time (BUT) measurement, conjunctival impression cytology and central corneal thickness (CCT) measurements were performed in one of the eyes of each patients before and 4 weeks after brinzolamide-timolol fixed combination therapy. All patients were asked to answer the OSDI questionnaire form about the ocular surface symptoms at baseline and at 1 week and 4 weeks follow-up visits.

RESULTS

After brinzolamide-timolol fixed combination theraphy Schirmer I, BUT and CCT values decreased but the only statistically significant decrease was seen in BUT test (P=0.03). OSDI scores increased during the follow-up but this increase was not statistically significant (P=0.22, P=0.42 respectively). Impression cytology findings ranged from 0.78±0.42 to 0.95±0.36 according to the Nelson classification. There was no statistically significant difference between baseline and 4 weeks follow up in impression cytology grades (P=0.15).

CONCLUSION

The results of our study indicate that short-term use of brinzolamide-timolol fixed combination theraphy does not have a profound effect on ocular surface except BUT values.

Patient perspectives when switching from Cosopt(®) (dorzolamide-timolol) to Azarga™ (brinzolamide-timolol) for glaucoma requiring multiple drug therapy

BACKGROUND

This study aimed to determine the impact of switching patients requiring multiple drug treatment from the dorzolamide-timolol fixed combination to the brinzolamide-timolol fixed combination and potential effects on tolerability and compliance.

METHODS

Patients were switched from dorzolamide-timolol to brinzolamide-timolol and questioned within a period of 4-26 weeks. Questions were asked to confirm if a specific side effect had been experienced, and then a numerical comparison between the two types of eye drop was made.

RESULTS

Thirty-one consecutive patients (12 males and 19 females aged 41-89 years) successfully completed the questionnaire. Comparison of the severity and chronicity of the side effects of the two types of fixed-combination eye drops showed that brinzolamide-timolol caused significantly less stinging for a shorter amount of time than dorzolamide-timolol; it also produced less eye redness for a significantly shorter amount of time. Brinzolamide-timolol produced more blurring, although the length of time this was present was similar to that for dorzolamide-timolol. No differences between the two eye drops were found for taste, overall impression, and likelihood of compliance.

CONCLUSION

Our study confirms the findings of other researchers pertaining to the side effect profile of brinzolamide-timolol after switching from dorzolamide-timolol, which is a reduction in stinging but an increase in blurred vision. The advantage of one eye drop over the other then becomes patient-specific, depending on which side effect they find most tolerable. We suggest that both eye drops are acceptable choices in treating patients with glaucoma, and are interchangeable if compliance becomes an issue because of a specific side effect of one eye drop or the other.

Fixed topical combinations in glaucomatous patients and ocular discomfort

OBJECTIVE

The purpose of this study was to verify the ocular comfort of a fixed topical combination of brinzolamide 1% plus timolol 0.5% suspension vs. dorzolamide 2% plus timolol 0.5% solution, both preserved with benzalkonium chloride (BAK), in patients with primary open-angle glaucoma (POAG) through subjective and objective methods. BAK is the most commonly used preservative in topical glaucoma medications.

METHODS

62 subjects were examined and included in the analysis. Each patient was asked to complete a questionnaire on symptoms (Ocular Surface Disease Index) and then underwent a series of examinations. The Ocular Protection Index evaluated the risk of damage to the ocular surface, and was expressed as the ratio between fluorescein breakup time and blinking interval. These and other analyses were repeated 30 days after instillation of the new eye drop treatment.

RESULTS

The results demonstrated that patients enrolled with the preserved fixed combination of dorzolamide or brinzolamide represented a subgroup of patients in which the discomfort symptoms were supposedly justified by the presence of BAK used chronically in antihypertensive drops. Ocular discomfort scores were significantly higher with dorzolamide/timolol than brinzolamide/timolol (p < 0.0001).

CONCLUSIONS

This work shows the better tolerability of brinzolamide 1% plus timolol 0.5% suspension, compared with dorzolamide 2% plus timolol 0.5% solution. Fortunately, some of the adverse reactions induced by preserved eye drop glaucoma medication are reversible after removing the preservatives. Both the potential for added benefit and patient compliance should be considered when selecting ocular hypotensive therapy.