Drugs for some common eye disorders

Treatment Guidelines from The Medical Letter® Published by The Medical Letter, Inc • 145 Huguenot Street, New Rochelle, NY 10801 • A Nonprofit Publication IN THIS ISSUE (starts on next page) Drugs for Some Common Eye Disorders p 79 Important Copyright Message The Medical Letter® publications are protected by US and international copyright laws Forwarding, copying or any distribution of this material is prohibited Sharing a password with a non-subscriber or otherwise making the contents of this site available to third parties is strictly prohibited By accessing and reading the attached content I agree to comply with US and international copyright laws and these terms and conditions of The Medical Letter, Inc For further information click: Subscriptions, Site Licenses, Reprints or call customer service at: 800-211-2769 FORWARDING OR COPYING IS A VIOLATION OF US AND INTERNATIONAL COPYRIGHT LAWS The Medical Letter publications are protected by US and international copyright laws Forwarding, copying or any other distribution of this material is strictly prohibited For further information call: 800-211-2769 Treatment Guidelines from The Medical Letter® Published by The Medical Letter, Inc • 145 Huguenot Street, New Rochelle, NY 10801 • A Nonprofit Publication Volume 10 (Issue 123) November 2012 (supercedes vol [Issue 89] January 2010) www.medicalletter.org Tables Some Topical Drugs for Glaucoma VEGF Inhibitors for Neovascular AMD Some Ophthalmic Antimicrobials Page 80 Page 82 Page 84 Drugs for Some Common Eye Disorders Related article(s) since publication Drugs for glaucoma, age-related macular degeneration, bacterial conjunctivitis, and dry eyes are reviewed here Drugs for the treatment of allergic conjunctivitis will be reviewed in a future issue of Treatment Guidelines on Drugs for Allergic Disorders In general, all eye drops should be given in doses of only one drop The average volume of a single drop is larger than the eyelid’s capacity to hold fluid; a second drop only washes out the first, may increase systemic absorption, and doubles the cost Ophthalmic drugs can have local and systemic adverse effects In addition, for some elderly patients, the complexity of selfadministering numerous ophthalmic drugs may be the limiting factor in their ability to care for themselves GLAUCOMA Glaucoma is a progressive optic neuropathy that is often associated with increased intraocular pressure (IOP), which is the only disease-related variable that ophthalmologists can modify Topical drugs for glaucoma are listed in the table on page 80 PROSTAGLANDIN ANALOGS — Topical prostaglandin analogs (PAs) typically lower IOP by 25-30% and stabilize it at a lower level throughout the day and night Dosed once a day, usually at night, they increase uveoscleral outflow PAs are now the drugs most frequently used for the treatment of glaucoma A new prostaglandin analog, tafluprost (Zioptan), was recently approved by the FDA.1 It is being marketed as the first preservative-free topical prostaglandin analog Tafluprost has not been shown to be tolerated better than any other drug in this class Adverse Effects – PAs can cause conjunctival hyperemia, and with long-term use, irreversible darkening of the iris in people with multicolor irides (green- brown, yellow-brown, or blue/gray-brown), increases in the length, thickness and number of eyelashes, and an increase in periorbital (eyelid) skin pigmentation PAs may also cause local irritation, itching, dryness, blurred vision and periorbital fat atrophy, which leads to deepening of the eyelid sulcus.2 They rarely may cause uveitis or cystoid macular edema, but have few, if any, systemic effects BETA BLOCKERS — Topical beta blockers decrease aqueous humor production They lower IOP by 20-25% with once- or twice-daily dosing The IOPlowering effect of beta blockers is much less at night The selective beta1-blocker betaxolol (Betoptic S, and generics) causes fewer systemic adverse effects than nonselective beta blockers, but it is not as effective in lowering IOP Adverse Effects – Beta blockers are generally well tolerated topically; rarely they may cause stinging, itching, redness and blurred vision Systemic effects, however, have limited their use as first-line therapy Adverse systemic effects can include fatigue, dizziness, bradycardia, respiratory depression, masking of hypoglycemia, and blocking the effects of beta2-agonists in the treatment of asthma Topical beta blockers should be used with caution in patients with asthma, bradycardia, or chronic obstructive pulmonary disease CARBONIC ANHYDRASE INHIBITORS — Carbonic anhydrase inhibitors (CAIs), like beta blockers, decrease IOP by decreasing production of aqueous humor CAIs are available in both oral and topical forms Oral CAIs include acetazolamide and methazolamide They can decrease IOP by 30-50%, but have many systemic adverse effects The topical CAIs dorzolamide (Trusopt, and generics) and brinzolamide (Azopt) typically decrease IOP by 15-20% throughout the day and night Both are FDA-approved for use Federal copyright law prohibits unauthorized reproduction by any means and imposes severe fines 79 Drugs for Some Common Eye Disorders Table Some Topical Drugs for Glaucoma Drug Some Formulations Some Available Sizes Usual Daily Dosage 0.005% soln* 2.5 mL drop qPM 0.01%, 0.03%2 soln* 0.004% soln 0.0015% soln 2.5, 5, 7.5 mL 2.5, mL 0.3 mL single-use containers4 drop qPM drop qPM drop qPM 0.5% soln* 0.25% susp* 1% soln* 0.25%, 0.5% soln* 0.5% soln* 0.3% soln* 5, 10, 15 mL 10, 15 mL 5, 10, 15 mL 5, 10, 15 mL5 5, 10, 15 mL 5, 10 mL drop qAM or bid Cost1 Prostaglandin Analogs Latanoprost – generic Xalatan (Pfizer) Bimatoprost – Lumigan (Allergan) Travoprost – Travatan Z (Alcon) Tafluprost – Zioptan (Merck) Beta Blockers Betaxolol – generic Betoptic S (Alcon) Carteolol – generic Levobunolol – generic Betagan (Allergan) Metipranolol – generic Optipranolol (Bausch & Lomb) Timolol – generic Betimol (Vistakon) Istalol (Bausch & Lomb) Timoptic Ocudose (Valeant) Timoptic (Merck) Carbonic Anhydrase Inhibitors Brinzolamide – Azopt (Alcon) Dorzolamide – generic Trusopt (Merck) Alpha-2 Agonists Apraclonidine – generic Iopidine (Alcon) Brimonidine – generic Alphagan P (Allergan) Cholinergic Agonists Pilocarpine – generic Isopto Carpine (Alcon) Carbachol – Isopto Carbachol (Alcon) Echothiophate iodide – Phospholine Iodide (Pfizer) Combinations Brimonidine/timolol – Combigan (Allergan) Timolol/dorzolamide – generic Cosopt (Merck) Cosopt PF (Merck) soln*6 soln* drop qAM or bid drop qAM or bid drop qAM or bid 50.86 152.55 13.10 4.25 31.73 16.48 20.31 2.67 53.10 86.33 262.129 99.84 5, 10, 15 mL 5, 10, 15 mL7 2.5, mL 0.2 mL individual units8 5, 10 mL7 drop bid drop bid 1% susp* 2% soln* 10, 15 mL 10 mL drop tid drop tid 112.10 40.56 69.79 0.5% soln* 0.5%, 1% soln* 0.2%,* 0.15% soln 0.1%, 0.15% soln 5, 10 mL 5, 10 mL10 5, 10, 15 mL drop tid 67.50 106.00 65.90 75.71 1%, 2%, 4% soln* 1%, 2%, 4% soln* 15 mL drop qid 31.50 68.90 1.5%, 3% soln* 15 mL drop bid-tid 55.90 0.125% soln11 mL drop bid 77.10 0.2%/0.5% soln* 5, 10 mL drop bid 87.63 0.5%/2% soln* 10 mL drop bid 0.5%/2% soln 0.2 mL single-use containers12 60.47 128.06 80.008 0.25%, 0.5% 0.25%, 0.5% 0.5% soln* 0.25%, 0.5% 0.25%, 0.5% soln soln*6 drop qAM or bid $19.06 100.23 96.98 89.20 97.003 drop tid * Contains benzalkonium chloride, which may cause irritation soln = solution; susp = suspension Wholesale acquisition cost (WAC) for the smallest size bottle available of the lowest strength Source: PricePointRx™ October 5, 2012 Reprinted with permission by FDB All rights reserved ©2012 http://www.firstdatabank.com/support/drug-pricing-policy.aspx Actual retail prices may vary The 0.03% formulation will no longer be produced in the US by the end of 2012 Cost of 30 single-use containers Supplied in cartons of 30 or 90 0.3-mL single-use containers packaged in foil pouches (10 containers per pouch) Only the 0.5% strength is available in a 15-mL bottle Also available as 0.25% and 0.5% ophthalmic gel-forming solution (generic and Timoptic XE) 0.25% solution is only available in 5-mL size Supplied in packages of 60 0.2-mL single-use containers Cost of 60 single-use containers 10 The 1% solution is available in 0.1-mL individual dispensers 11 Supplied as a powder for reconstitution (1 bottle of powder for solution + mL diluent) 12 Supplied in packages of 60 or 180 0.2-mL single-use containers in foil pouches (15 containers per pouch) 80 Treatment Guidelines from The Medical Letter • Vol 10 ( Issue 123) • November 2012 Drugs for Some Common Eye Disorders three times daily, but they are often prescribed twice daily and are most often used in patients already being treated with a PA Adverse Effects – Generally the only systemic adverse effect of topical CAIs has been bitter taste; they are better tolerated than beta blockers They can cause stinging, redness, burning, conjunctivitis, dry eyes and blurred vision CAIs should be used with caution after corneal transplantation because long-term use may lead to graft decompensation They are sulfonamide derivatives, but topical CAIs have been reported to be generally well tolerated in patients with sulfonamide allergies ALPHA AGONISTS — Like beta blockers and CAIs, alpha agonists decrease IOP by decreasing aqueous humor production, but they may also increase uveoscleral outflow The selective alpha2-agonist brimonidine (Alphagan P, and generics) typically lowers IOP by 15-20% during the day, but not during the night.3 Apraclonidine (Iopidine, and generics), a derivative of clonidine, is sometimes used for prophylaxis against acute increases in IOP after laser procedures; tachyphylaxis and local allergic reactions have limited its continued use for long-term IOP control.4 The nonselective alpha agonists epinephrine and dipivefrin are seldom used now because of local and systemic side effects Adverse Effects – Fatigue, somnolence (especially in young children), and local allergic reactions occur frequently with alpha agonists Topical effects include dry eyes, stinging, conjunctival hyperemia and foreign-body sensation A recent change in the preservative used for brimonidine and a decrease in its concentration from 0.15% to 0.1% may improve the drug’s tolerability Brimonidine can cross the blood-brain barrier and cause systemic hypotension in infants and children; it has caused respiratory depression in children 4 times a day Ointment formulations can be used at night and during the day in severe cases 10 11 12 13 14 Tafluprost (Zioptan) - a new topical prostaglandin for glaucoma Med Lett Drugs Ther 2012; 54:31 K Inoue et al Deepening of the upper eyelid sulcus caused by types of prostaglandin analogs J Glaucoma 2012; August 29 (epub) JH Liu et al Diurnal and nocturnal effects of brimonidine monotherapy on intraocular pressure Ophthalmology 2010; 117:2075 S Arthur and LB Cantor Update on the role of alpha-agonists in glaucoma management Exp Eye Res 2011; 93:271 RJ Casson et al Efficacy and safety of bimatoprost as replacement for latanoprost in patients with glaucoma or ocular hypertension: a uniocular switch study J Glaucoma 2009; 18:582 LP Aiello Targeting intraocular neovascularization and edema – one drop at a time N Engl J Med 2008; 359:967 Pegaptanib sodium (Macugen) for macular degeneration Med Lett Drugs Ther 2005; 47:55 Ranibizumab (Lucentis) for macular degeneration Med Lett Drugs Ther 2006; 48:85 PJ Rosenfeld et al Ranibizumab for neovascular age-related macular degeneration N Engl J Med 2006; 355:1419 CD Regillo et al Randomized, double-masked, sham-controlled trial of ranibizumab for neovascular age-related macular degeneration: PIER Study year Am J Ophthalmol 2008; 145:239 BA Frost and MA Kainer Safe preparation and administration of intravitreal bevacizumab injections N Engl J Med 2011; 365:2238 CATT Research Group Ranibizumab and bevacizumab for neovascular age-related macular degeneration N Engl J Med 2011; 364:1897 CATT Research Group Ranibizumab and bevacizumab for treatment of neovascular age-related macular degeneration: two-year results Ophthalmology 2012; 119:1388 Aflibercept (Eylea) for age-related macular degeneration Med Lett Drugs Ther 2012; 54:9 Treatment Guidelines from The Medical Letter • Vol 10 ( Issue 123) • November 2012 85 Drugs for Some Common Eye Disorders 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 S Day et al Ocular complications after anti-vascular endothelial growth factor therapy in Medicare patients with age-related macular degeneration Am J Ophthalmol 2011; 152:266 FG Holz et al Safety and efficacy of a flexible dosing regimen of ranibizumab in neovascular age-related macular degeneration: the SUSTAIN study Ophthalmology 2011; 118:663 Photodynamic therapy with verteporfin (Visudyne) for macular degeneration Med Lett Drugs Ther 2000; 42:81 NM Bressler Treatment of Age-Related Macular Degeneration with Photodynamic Therapy (TAP) study group Photodynamic therapy of subfoveal choroidal neovascularization in age-related macular degeneration with verteporfin: two-year results of randomized clinical trials-tap report Arch Ophthalmol 2001; 119:198 M Azab et al Verteporfin therapy of subfoveal minimally classic choroidal neovascularization in age-related macular degeneration: 2year results of a randomized clinical trial Arch Ophthalmol 2005; 123:448 JB Jonas et al Exudative age-related macular degeneration treated by intravitreal triamcinolone acetonide A prospective comparative nonrandomized study Eye (Lond) 2005; 19:163 Age-Related Eye Disease Study Research Group A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss: AREDS report no Arch Ophthalmol 2001; 119:1417 Nutritional support for macular degeneration Med Lett Drugs Ther 2010; 52:63 The ATBC Cancer Prevention Study Group The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers The Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group N Engl J Med 1994; 330:1029 GS Omenn et al Effects of a combination of beta carotene and vitamin A on lung cancer and cardiovascular disease N Engl J Med 1996; 334:1150 ER Miller 3rd et al Meta-analysis: high-dosage vitamin E supplementation may increase all-cause mortality Ann Intern Med 2005; 142:37 I Bairati et al Antioxidant vitamins supplementation and mortality: a randomized trial in head and neck cancer patients Int J Cancer 2006; 119:2221 W Haas et al Integrated analysis of three bacterial conjunctivitis trials of besifloxacin ophthalmic suspension, 0.6%: etiology of bacterial conjunctivitis and antibacterial susceptibility profile Clin Ophthalmol 2011; 5:1369 Opthalmic azithromycin (AzaSite) Med Lett Drugs Ther 2008; 50:11 Ophthalmic Besifloxacin (Besivance) Med Lett Drugs Ther 2009; 51:101 WB Jackson Management of dysfunctional tear syndrome: a Canadian consensus Can J Ophthalmol 2009; 44:385 AH Wander and BH Koffler Extending the duration of tear film protection in dry eye syndrome: review and retrospective case series study of the hydroxypropyl cellulose ophthalmic insert Ocul Surf 2009; 7:154 Ophthalmic cyclosporine (Restasis) for dry eye disease Med Lett Drug Ther 2003; 45:42 HD Perry et al Evaluation of topical cyclosporine for the treatment of dry eye disease Arch Ophthalmol 2008; 126:1046 Coming Soon in Treatment Guidelines: Screening Tests for Cancer – Dec 2012 Drugs for Acne, Rosacea and Psoriasis – Jan 2013 Follow us on Twitter @MedicalLetter Coming soon: Our Facebook page Treatment Guidelines ® from The Medical Letter EDITOR IN CHIEF: Mark Abramowicz, M.D EXECUTIVE EDITOR: Gianna Zuccotti, M.D., M.P.H., F.A.C.P., Harvard Medical School EDITOR: Jean-Marie Pflomm, Pharm.D ASSISTANT EDITORS, DRUG INFORMATION: Susan M Daron, Pharm.D., Corinne E Zanone, Pharm.D CONSULTING EDITORS: Brinda M 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Call us at 800-211-2769 or 914-235-0500 or e-mail us at: custserv@medicalletter.org Questions start on next page Treatment Guidelines from The Medical Letter • Vol 10 ( Issue 123) • November 2012 DO NOT FAX OR MAIL THIS EXAM To take CME exams and earn credit, go to: medicalletter.org/CMEstatus Issue 123 Questions Adverse effects that have been reported with prostaglandin analogs include: a conjunctival hyperemia b periorbital skin pigmentation c blurred vision d all of the above Issue 123 A 57-year-old man who takes salmeterol for asthma asks his physician to recommend a topical drug for glaucoma Which of the following should you recommend? a tafluprost b timolol c aflibercept d glycerol Issue 123 Irreversible darkening of the iris in people with multicolor irides has been reported with long-term administration of: a prostaglandin analogs b carbonic anhydrase inhibitors c beta blockers d cholinergic agonists Issue 123 Which of the following has caused somnolence and respiratory depression in young children? a apraclondine b pilocarpine c brimonidine d bevacizumab Issue 123 A 64-year-old woman who is undergoing an ophthalmic laser procedure asks her physician to recommend a topical drug to prevent an acute increase in intraocular pressure Which of the following would you recommend? a ranibizumab b glycerol c mannitol d apraclonidine Issue 123 Retinal detachment, brow ache and corneal toxicity have been reported with: a pilocarpine b travoprost c dorzolamide d brimonidine Issue 123 Which of the following vascular endothelial growth factor inhibitors has been shown to maintain vision in a large majority of patients with wet age-related macular degeneration? a ranibizumab b aflibercept c bevacizumab d all of the above Issue 123 Transient back pain and photosensitivity have been reported with: a verteporfin b pegaptanib c triamcinolone acetonide d aflibercept Issue 123 Dry eyes can be caused by: a poor lid function b anticholinergic drugs c selective serotonin receptor antagonists d all of the above Issue 123 10 Among the most common bacterial pathogens associated with acute conjunctivitis in adults is: a Staphylococcus aureus b Moraxella catarrhalis c Staphylococcus epidermidis d Staphylococcus saprophyticus Issue 123 11 Topical corticosteroids used for the treatment of dry eyes have been reported to: a cause cataracts b increase intraocular pressure c both a and b d none of the above Issue 123 12 A 64-year-old man with non-neovascular “dry” age-related macular degeneration asks his physician to recommend a topical drug that could slow the progression of disease Which of the following would you recommend? a bevacizumab b aflibercept c ranibizumab d none of the above Issue 123 ACPE UPN: 0379-0000-12-123-H01-P; Release: October 2012, Expire: October 2013 Treatment Guidelines from The Medical Letter • Vol 10 ( Issue 123) • November 2012 ... www.medicalletter.org Tables Some Topical Drugs for Glaucoma VEGF Inhibitors for Neovascular AMD Some Ophthalmic Antimicrobials Page 80 Page 82 Page 84 Drugs for Some Common Eye Disorders Related article(s)... FDA-approved for use Federal copyright law prohibits unauthorized reproduction by any means and imposes severe fines 79 Drugs for Some Common Eye Disorders Table Some Topical Drugs for Glaucoma Drug Some. .. • November 2012 Drugs for Some Common Eye Disorders Aflibercept (Eylea) is a fusion protein FDA-approved for treatment of wet AMD It acts as a decoy VEGF receptor, competing for binding of VEGF