Glaucoma Medical Treatment
exposure, the higher is the probability for increased bleb scarring after trabeculectomy. Thus, when surgery is indicated it is better to offer it early or to propose a consultation with a glaucoma specialist than to continue an unsuccessful topical medication until the clinically significant and irreversible damage develops.24
Original Drug or Generic Medication? The role of generics in the treatment of glaucoma has been gaining special importance, because increasingly, latanoprost has become available in generic forms in several countries. Generics are cheaper than the original product (no need to cover the cost of the drug development) and theoretically equal in terms of efficacy and safety. However, for ophthalmic products for which no pharmacokinetic studies are possible (we cannot sample the eye to measure comparative intraocular drug concentrations between the original product and each of the many generics), equal efficacy and safety can be shown only by head-to-head evidence-based clinical studies. Such studies are seldom conducted, and in large regions of the world,
1. Azuaro-Blanco A, Jampel H, Treatment goals. Target IOP. In: Weinreb RN, Arie M, Susanna R, et al., for the World Glaucoma Association, Medical Treatment of Glaucoma, Amsterdam: Kugler Publications, 2010;23–6.
2. American Academy of Ophthalmology, Preferred Practice Pattern: Primary Open-angle Glaucoma, San Francisco: American Academy of Ophthalmology, 2010;16–9. Available at:
http://one.aao.org/CE/PracticeGuidelines/PPP_Content.aspx? cid=93019a87-4649-4130-8f94-b6a9b19144d2 (accessed 28 November 2011),
3. South East Asia Glaucoma Interest Group, Asia Pacific Glaucoma Guidelines, Singapore: South East Asia Glaucoma Interest Group, 2004;31–40.
4. European Glaucoma Society, Terminology and Guidelines for Glaucoma, 3rd edition, Savona: Dogma SRL, 2008;117–69. Available at:
www.eugs.org/eng/EGS_guidelines.asp (accessed 28 November 2011).
5. Krupin T, Liemann JM, Greenfield DS, et al., on behalf of the Low-Pressure Glaucoma Study Group, A randomized trial of brimonidine versus timolol in preserving visual function: results from the Low-Pressure Glaucoma Treatment Study, Am J Ophthalmol, 2011;151:671–81.
6. Brandt JD, Roberts C, Sherwood MB, Sheets CW, The impact of central corneal thickness and corneal biomechanics on tonometry. In: Shaarawy TM, Sherwood MB, Hitchings RA, Crowston JG, Glaucoma, Volume 1, Saunders-Elsevier, 2009;207–12.
7. Bengtsson B, Leske C, Hyman L, Heilj A, for the Early Manifest Glaucoma Trial Group, Fluctuation of intraocular pressure and glaucoma progression in the Early Manifest Glaucoma Trial, Ophthalmology, 2007;114;205–9.
8. Konstas AGP, Holló G, Astakhov YS, et al., Factors associated with long-term progression or stability in exfoliation glaucoma, Arch Ophthalmol, 2004;122:29–33.
simple expert summaries are sufficient to receive a waiver from comparative studies during the registration process. Certain physical characteristics of the bottle (e.g., transparency, ease of opening, size of the droplet) are not regulated sufficiently. This may result in surprisingly large between-generics differences regarding the total daily dosage of the active ingredient. Thus, the use of generics may comprise some problems and the risk–benefit relationship needs to be investigated separately for each individual generic product.
Summary
Medical treatment of open-angle glaucoma has developed considerably in recent years. Several fixed-combination drops and non-BAK preserved preparations have become widely available. However, compliance remains low among glaucoma patients, treatment selection is still frequently suboptimal and in many cases surgery is postponed until severe functional damage has developed. To improve this situation the use of regional and/or national glaucoma diagnostic and treatment guidelines2–4
is recommended for everyday routine practice. n
9. The AGIS Investigators, The Advanced Glaucoma Intervention Study (AGIS): 7. The relationship between control of intraocular pressure and visual field deterioration, Am J Ophthalmol, 2000;130:429–40.
10. Caprioli J, Coleman AL, Intraocular pressure fluctuation: risk factors for visual field progression at low intraocular pressures in the Advanced Glaucoma Intervention Study, Ophthalmology, 2008;115:1123–9.
11. Hong S, Seong GJ, Hong YJ, Long-term intraocular pressure fluctuation and progressive visual field deterioration in patients with glaucoma and low intraocular pressure after a triple procedure, Arch Ophthalmol, 2007;125:1010–3.
12. Stewart WC, Konstas AGP, Nelson LA, Kruft B, Meta-analysis of 24-hour intraocular pressure studies evaluating the efficacy of glaucoma medicines, Ophthalmology, 208;115:1117–22.
13. Brignole-Baudouin F, Riancho L, Liang H, et al., In vitro comparative toxicology of polyquad-preserved and benzalkonium chloride-preserved travoprost/timolol fixed combination and latanoprost timolol fixed combination, J Ocul Pharmacol Ther, 2011;27;273–80.
14. Liang H, Pauly A, Riancho L, et al., Toxicological evaluation of preservative-containing and preservative-free topical prostaglandin analogues on a three-dimensional-reconstituted corneal epithelium system, Br J Ophthalmol, 2011;95:869–75.
15. Holló G, Kóthy P, Intraocular pressure reduction with travoprost/timolol fixed combination, with and without adjunctive brinzolamide, in glaucoma, Curr Med Res Opin, 2008;24:1755–61.
16. Uusitalo H, Pillunat LE, Ropo A, on behalf of the Phase III Study Investigators, Efficacy and safety of tafluprost 0.0015% versus latanoprost 0.005% eye drops in open-angle glaucoma and ocular hypertension: 24-month results of a
randomized, double-masked phase III study, Acta Ophthalmol, 2010;88:12–9.
17. Hommer A, Ramez OR, Burchert M, Kimmich F, IOP-lowering efficacy and tolerability of preservative-free tafluprost 0.0015% among patients with ocular hypertension or glaucoma, Curr Med Res Opin, 2010;26:1905–13.
18. Gandolfi S, Paredes T, Goldberg I, et al., for the Travoprost BAK-free Clinical Study Group, Comparison of a travoprost BAK-free formulation preserved with polyquaternium-1 with BAK-preserved travoprost in ocular hypertension or open-angle glaucoma, Eur J Ophthalmol, 2012;22:32–42.
19. Kitazawa Y, Smith P, Sasaki N, et al., Travoprost 0.004%/timolol 0.5%-fixed combination with and without benzalkonium chloride: a prospective, randomized, double-masked comparison of safety and efficacy, Eye, 2011;25:1161–9.
20. Sleath B, Robin AL, Covert D, et al., Patient-reported behavior and problems in using glaucoma medications, Ophthalmology, 2006;113:431–6.
21. Robin AL, Novack GD, Covert DW, et al., Adherence in glaucoma: objective measurements of one-daily and adjunctive medication use, Am J Ophthalmol, 2007;144:533–40.
22. Holló G, Kóthy P, Géczy A, Vargha P, Personality traits, depression, and objectively measured adherence to once daily prostaglandin analog medication in glaucoma, J Glaucoma, 2009;18:288–92.
23. Claxton AJ, Cramer J, Pierce C, A systematic review of the associations between dose regimens and medication compliance, Clin Therapeutics, 2001;23:1296–310.
24. Fechtner R, Hitchings R, Indications for glaucoma surgery. In: Weinreb RN, Crowston JG, Glaucoma Surgery (International Glaucoma Societies, Consensus Series No.2), Hague: Kugler Publications, 2005;9–20.
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