One-Year Follow-Up Study of Changes in Prostaglandin-Associated Periorbital Syndrome After Switch From Conventional Prostaglandin F2alfa to Omidenepag Isopropyl

Emerging drugs for the treatment of glaucoma: a review of phase II & III trials

INTRODUCTION

Glaucoma is a progressive optic neuropathy and the leading cause of irreversible vision loss. By 2040, the number of individuals with glaucoma is expected to nearly double. The only known modifiable risk factor for glaucoma is intraocular pressure. Topical medications are often used as first-line therapies. Although there are numerous available treatments, there continues to be a need for the development of new medical therapies due to variable response, intolerable side-effect profiles in some patients, and elevated intraocular pressure refractory to other treatments.

AREAS COVERED

This review will cover glaucoma medications currently undergoing phase II and III of drug development.

EXPERT OPINION

There are numerous drugs currently in development that have demonstrated significant and clinically relevant reduction of intraocular pressure. Differentiating factors include improved tolerability, novel mechanisms of action, multiple mechanisms of action, or superior IOP reduction. However, the availability of generic prostaglandin analogs may limit adoption of these novel compounds as first-line agents, except for certain subgroups of glaucoma patients. Use as adjuvant or second-line therapy appears more likely for the majority of glaucoma patients.

Efficacy and Safety of Omidenepag Isopropyl 0.002% Ophthalmic Solution: A Retrospective Analysis of Real-World Data in Japan

Introduction

This study aimed to clarify the efficacy and safety of omidenepag isopropyl (OMDI) in a retrospective, real-world, multicenter setting.

Methods

A retrospective medical chart review of patients with glaucoma and ocular hypertension receiving OMDI from November 2018 to November 2019 with at least 12 weeks of follow-up was conducted in 11 eye clinics in Japan. The participants were categorized into three therapy groups, designated the naïve monotherapy, switching monotherapy, and concomitant therapy groups. The main outcome measures were the change in intraocular pressure (IOP) at week 4 and week 12 after the initiation of OMDI treatment, and frequency of adverse drug reactions.

Results

Data were collected from 827 patients. The baseline IOP in the naïve group was 16.6 ± 4.2 mmHg. The mean IOP reduction at week 4 and week 12 was − 2.9 ± 3.2 mmHg (P < 0.0001) and − 2.5 ± 2.9 mmHg (P < 0.0001), respectively. Eyes with baseline IOP less than 16 mmHg also showed a significant reduction of IOP of − 1.4 ± 2.0 mmHg at week 12. OMDI significantly reduced IOP not only in eyes with primary open-angle glaucoma but also in eyes with primary angle-closure glaucoma and secondary glaucoma. In the switching monotherapy group, IOP did not change significantly after switching from most classes of medications to OMDI, but further IOP reduction was observed in the case of switching from beta-blockers to OMDI. The frequency of adverse drug reactions was 14.1% in all participants, and the most common adverse reaction was ocular hyperemia (7.6%). No serious and severe side effects were observed in this study.

Conclusion

OMDI showed an IOP-lowering effect in eyes with various types of glaucoma and using various therapeutic regimens in real-world clinical practice. In addition, OMDI did not show any serious and severe side effects, suggesting the potential of OMDI as a first-line medicine for the treatment of glaucoma.

Trial Registration

University Hospital Medical Information Network (UMIN): 000040040.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-022-02069-6.

Efficacy and Patient Tolerability of Omidenepag Isopropyl in the Treatment of Glaucoma and Ocular Hypertension

Current therapeutic approaches for glaucoma aim to reduce intraocular pressure (IOP), which is the only available and reliable strategy proven to control the risk of disease development and progression. Omidenepag isopropyl (OMDI) is a novel topical ocular hypotensive agent that was launched onto the market for the treatment of glaucoma and ocular hypertension (OHT). After topical instillation and during corneal penetration, OMDI is converted into the active metabolite omidenepag (OMD), which behaves as a non-prostaglandin, selective E-prostanoid subtype 2 (EP2) receptor agonist. The topical administration of 0.002% OMDI once-daily (QD) possesses a 20–35% IOP-lowering effect, comparable to that of prostaglandin analogs targeting F-prostanoid (FP) receptor QD, which are the current first-line for pharmaceutical reduction of IOP. However, the mechanism of action and adverse events (AEs) of OMDI are different from those of FP receptor agonists. OMDI reduces IOP by enhancing both conventional trabecular and uveoscleral outflow facilities without complications of prostaglandin-associated periorbitopathy (PAP) seen with FP receptor agonists. Moreover, OMDI was also effective and well-tolerated in non-/poor responders to latanoprost and showed a stable IOP-lowering effect for one year, and its concomitant use with timolol enhanced the IOP-lowering effect. OMDI demonstrated acceptable safety and tolerability with good adherence and can be used in almost every patient. However, OMDI has some AEs such as conjunctival hyperemia, corneal thickening, macular edema/cystoid macular edema and ocular inflammation. Moreover, OMDI is contraindicated in patients who are allergic to the product, in aphakic or pseudophakic eyes, and in combination with tafluprost eye drops. If used appropriately in the right patients, OMDI could be an effective treatment option for glaucoma and OHT as a first-line alternative to FP agonists. Here, we summarize the results of clinical studies of OMDI and discuss its efficacy and patient tolerability in glaucoma and OHT in this review.

Effect of Prostaglandin E2 Agonist Omidenepag on the Expression of Matrix Metalloproteinase in Trabecular Meshwork Cells

Purpose

To investigate the effects of prostaglandin E2 agonist omidenepag (OMD) on the expression of matrix metalloproteinase (MMP) in human trabecular meshwork (TM) cells.

Methods

Primarily cultured human TM cells were exposed to 0, 1, 10, or 40 μmol/L OMD for 3 days. The permeability through the TM cell monolayer was assessed using carboxyfluorescein. Expressions of messenger ribonucleic acid and protein levels of MMP-1, MMP-3, and MMP-9 were measured by reverse transcription polymerase chain reaction and Western blotting, respectively. Also, the permeability, expression of messenger ribonucleic acid, and protein levels of MMPs were measured after exposure to 1 μmol/L latanoprost free acid (LAT).

Results

OMD and LAT did not affect the cellular survival (all p > 0.05). Each concentration of OMD and LAT did not affect the permeability of carboxyfluorescein significantly (all p > 0.05). LAT increased the level of MMP-1 protein but did not increase the levels of MMP-3 and MMP-9 proteins. Each concentration of OMD did not affect the levels of MMP-1, MMP-3, and MMP-9 proteins (all p > 0.05)

Conclusions

In TM cells, prostaglandin E2 agonist OMD did not increase the permeability through the TM cell monolayer, and the protein levels of MMPs. These suggest that the direct effect on the trabecular outflow by OMD may be limited.

Cystoid Macular Edema Associated with Omidenepag Isopropyl in Phakic Eyes after Laser Iridotomy: A Case Report

Decreased vision and cystoid macular edema (CME) developed in phakic eyes of a patient who underwent laser iridotomy after changing the glaucoma eye drops from carteolol 2% long-acting ophthalmic solution to omidenepag isopropyl 0.002%. CME completely disappeared at approximately 2 months after discontinuation of omidenepag isopropyl in conjunction with the use of bromfenac sodium 0.1%.

Twelve-month efficacy and safety of omidenepag isopropyl, a selective EP2 agonist, in open-angle glaucoma and ocular hypertension: the RENGE study

PURPOSE

To assess the long-term safety and efficacy of omidenepag isopropyl (OMDI) 0.002% (a first-in-class, selective, non-prostaglandin, prostanoid EP2 receptor agonist), alone or administered concomitantly with timolol 0.5%, in patients with open-angle glaucoma (OAG, including normal-tension and exfoliation glaucoma) or ocular hypertension (OHT).

STUDY DESIGN

Open-label, multicenter, Phase 3 study (NCT02822729).

METHODS

Patients aged ≥ 20 years, with OAG or OHT, and a baseline diurnal intraocular pressure (IOP) ≥ 16- < 22 mmHg (Group 1) or ≥ 22- ≤ 34 mmHg (Groups 2 and 3) were enrolled. All patients (N = 125) received OMDI 0.002% once daily. Group 3 also received timolol 0.5% twice daily. IOP was measured at baseline and at Weeks 2, 4, 8, 12, 26, 40, and 52.

RESULTS

Significant reductions in mean diurnal IOP from baseline occurred at every visit (P < 0.0001). Mean ± SE diurnal IOP reduction at Week 52 was -3.7 ± 0.3 mmHg (Group 1), -5.6 ± 0.5 mmHg (Group 2), and -8.4 ± 0.6 mmHg (Group 3). Most adverse events (AEs) were mild, and no serious treatment-related AEs were reported. Conjunctival hyperemia (incidence: monotherapy [Groups 1 and 2], 18.8%; concomitant [Group 3], 45.0%) and macular edema (ME)/cystoid macular edema (CME) (incidence: monotherapy, 11.8%; concomitant, 15.0%) occurred most frequently. All treatment-related ME/CME cases occurred in pseudophakic eyes and responded to standard-of-care treatment and study drug discontinuation.

CONCLUSIONS

In this study, OMDI 0.002%, alone or administered concomitantly with timolol 0.5%, resulted in sustained IOP reduction over 52 weeks in patients with OAG or OHT. Concomitant treatment resulted in increased efficacy and increased incidence of conjunctival hyperemia.

A Randomized Phase 2 Trial Comparing Omidenepag Isopropyl 0.002% Once and Twice Daily in Subjects With Primary Open-angle Glaucoma or Ocular Hypertension (SPECTRUM-6)

PRCIS

No significant difference was found between the intraocular pressure (IOP) lowering of omidenepag isopropyl 0.002% once daily (QD) and twice daily (BID). However, adverse events (AEs) were higher in the BID arm; thus, QD dosing is the preferred dosing frequency for further investigation.

PURPOSE

This phase 2, randomized, double-masked, parallel-arm, multicenter study (NCT03858894) was conducted in the United States to examine whether the efficacy and safety of omidenepag isopropyl 0.002% BID dosing was superior to QD dosing in subjects with primary open-angle glaucoma or ocular hypertension.

METHODS

Randomized subjects (1:1) received omidenepag isopropyl 0.002% QD (n=50) or BID (n=48) for 6 weeks (after a ≤4-week washout period). IOP was measured at 8:00 am, 12:00 pm, and 4:00 pm at baseline and weeks 2 and 6. The primary efficacy endpoint was IOP at each timepoint at weeks 2 and 6. AEs were evaluated.

RESULTS

Baseline mean diurnal IOP (±SD) post washout was 25.4±2.9 mm Hg (BID) and 24.6±1.9 mm Hg (QD). At weeks 2 and 6, clinically significant IOP reductions from baseline were observed for omidenepag isopropyl BID and QD treatments. Least-squares mean (±SE) IOP differences (BID versus QD) were not statistically significant (week 2: 0.44±0.68 to 1.08±0.65 mm Hg; week 6: 0.36±0.63 to 0.68±0.68 mm Hg) at any timepoint (all P > 0.05). AEs were 3-fold greater in the BID arm (41.7%; QD: 14.0%); the most frequently reported AE was conjunctival/ocular hyperemia (BID: 22.9%; QD: 2.0%). Five subjects discontinued omidenepag isopropyl prematurely, 4 of 5 owing to AEs (BID: 4; QD: 0).

CONCLUSION

In this study, the benefit-risk profile of omidenepag isopropyl 0.002% QD was more favorable than the benefit-risk profile of BID. This difference was driven by a higher incidence of local tolerability issues in the BID arm.

Periorbital Hyperpigmentation—Dark Circles under the Eyes; Treatment Suggestions and Combining Procedures

Periorbital hyperpigmentation (POH) is a frequent concern among both young and adult patients. The etiology is multifactorial with a genetic background. Prevalence is higher in darker skin types. It has been estimated as high as 30% in a recent Indian study. Females are often more disappointed by POH than males. Treatment has to consider underlying pathologies and patients’ needs. We present our treatment algorithm for POH. In this study, 74 patients with POH, 64 females (86.5%) and 10 males (13.3%), were treated. Of these, 39 patients (53%) had a family history of POH. The age range of patients was 18−57 years (average: 36.1 years). In case of tear trough deformity, soft tissue augmentation was used by injection of hyaluronic acid gel, calcium hydroxylapatite, or autologous fat. Blepharoplasty with partial fat pad resection or repositioning via arcus marginalis release was used to correct severe orbital fat herniation and excess of the lower lid skin. Melanin hyperpigmentation of the skin was improved by sessions of Q-switched 1064 and 532 nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser. Small vessels (capillaries and veins) were targeted by a 1064 nm long-pulsed Nd-YAG laser. Sessions of intense pulsed light (IPL) or CO2 fractional laser were employed to improve skin texture and fine lines. Topical hyaluronic acid-based formulations may be used as adjuvant self-treatment by patients. For pigmented and mixed-type POH, ultraviolet light protection is recommended as a maintenance treatment. By the use of various technologies, treatment can be individually tailored.