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Glaucoma pharmacotherapy

Nathan Radcliffe, MD

New York Eye Surgical Center

New York University

April 1, 2016

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Disclosures

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Glaucoma

A progressive disease characterized by retinal ganglion

cell and axonal deterioration accompanied by visual

functional loss

Difference Follow-up Baseline

Ritch, Shields, Krupin. The Glaucomas, Vol 1. Mosby, 1989.

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Medical Therapy History

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The challenges of medical

therapy: a case

58 year old myopic man with OHTN

Using latanoprost ou qhs, forgets drops “sometimes”

IOP 25 mm Hg OU, CCT 580 ou

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Steps to IOP lowering

Prescription written

Prescription presented to pharmacist & dispensed

Medication applied to eye

Medication activates target

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Prescription fill rates?

Of almost14,000 patients prescribed

glaucoma medications:

Only 10% of patients will endure 1 year

without refill gaps

The medication possession ratio was 0.64.

Difficult topic to study for methodological

reasons

Friedman, D., et al. IOVS. 2007; 48:5052-5057

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Once they are taking the drops…

Only 39% of attempted eye drop

placements hit the eye1

On average 1.4 drops are delivered per

attempt1

In a typical clinical trial, 16.5% will

experience adverse events and 28.1%

will discontinue therapy2

1. Hennessy, AL, et. al. Am J Ophthal. 2011; 152:982-8.

2. Sherwood, M., et al. Arch Ophthalmol. 2006;124:1230-1238

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Up to 33% of glaucoma patients touch the bottle to

their eye during eye drop application!

Hennessy, AL, et. al. Am J Ophthal. 2011; 152:982-8.

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Does it matter?

Poor adherence is associated with visual

field progression1

1. Stewart WC et al. Am J Ophthalmol. 1993;116:176–181.

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Question:

Is it ideal to use a therapy that we know many patients:

Forget to take

Can not get into their eyes

My answer:

Eye drop therapy has a welcomed place in glaucoma management, but other therapies including laser and sustained delivery may help us avoid the above problems

When we use drops, we should use the ones that are most powerful and best tolerated to avoid the need for additional drops and give our patients the best chance of sucess

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Selective Laser Trabeculoplasty

The SLT/Med Study group found that SLT laser and

medications performed similarly in a group of patients

randomized to each treatment, with a 6 to 7 mm Hg

reduction in both groups

1. Realini T. Selective laser trabeculoplasty for the management of open-angle glaucoma in St. Lucia. JAMA Ophthalmol.

2013;131(3):321-7.

2. 2. Katz LJ, Steinmann WC, Kabir A, Molineaux J, Wizov SS, Marcellino G; SLT/Med Study Group. Selective laser

trabeculoplasty versus medical therapy as initial treatment of glaucoma: a prospective, randomized trial. J Glaucoma.

2012;21(7):460-8.

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Trabeculoplasty

Ramulu PY, et al. Ophthalmology. 2007;114:2265-70.

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Ocular Surgery News 2012

Audience Response Question:

What therapy would you select for yourself if you

developed ocular hypertension or glaucoma?

50% trabeculoplasty, 50% drops

What therapy would you select for your patient as

primary therapy?

90% drops, 10% trabeculoplasty

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Current treatment paradigm

Initiate with Prostaglandin analog (?SLT)

(~80% acceptance rate)

Single agent Fixed Combination

Surgery

?SLT

?SLT

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Sustained Release

Allergan

Safety and Efficacy of Bimatoprost Sustained-Release

(SR) in Patients With Open-Angle Glaucoma or Ocular

Hypertension (Phase three trial underway)1

Regarding the Phase II study:2 “All dose strengths of

Bimatoprost SR were comparable with topical

bimatoprost 0.03% in overall IOP reduction through

week 16.”

1. https://clinicaltrials.gov/ct2/show/NCT02250651

2. http://www.allergan.com/news/news/thomson-reuters/positive-phase-i-ii-

interim-data-of-bimatoprost-su

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Sustained Release

ForSight Vision 5

Bimatoprost sustained release ring (Phase 2)

Other options in the pipeline

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Sustained Release

Mati Therapeutics

Punctal Plug Drug Delivery System (PPDS)

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Summary

Glaucoma is a chronic and progressive disease

that requires consistent effective treatment

IOP lowering therapy with medications can be

effective but is limited by compliance, which is a

major problem

Sustained delivery treatments may be part of the

solution

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Thank you!!!