Glaucoma 2025: Treatment, Medications, & Diagnosis - PDF

Glaucoma Michael A. Zappone, Pharm.D. Assistant Professor Department of Pharmacy Practice February 11, 2025 Objectives – Differentiate between the two major types of glaucoma – Identify medications that can increase intraocular pressure – Understand the Patient Care Process for the Management o...

Glaucoma Michael A. Zappone, Pharm.D. Assistant Professor Department of Pharmacy Practice February 11, 2025 Objectives – Differentiate between the two major types of glaucoma – Identify medications that can increase intraocular pressure – Understand the Patient Care Process for the Management of Glaucoma – Differentiate between the medications used in the treatment of Open-Angle Glaucoma – Select an appropriate drug therapy for the treatment of Open-Angle Glaucoma Glaucoma – Eye disease that results in: – Damage to the optic nerve (optic neuropathy) – Loss of the visual field – Most cases: Intraocular pressure (IOP) > normal range (12-22 mmHg) – What causes IOP to increase? – Genetics – Age – Medications – Goal of treatment: – Reduce IOP Drugs That Can Increase Anticholinergics (ex. antihistamines, oxybutynin, tolterodine, benztropine, scopolamine, tricyclic antidepressants) IOP Decongestants (ex. pseudoephedrine) Chronic steroids, especially eye drops such as prednisolone (Pred Forte) Topiramate (Topamax) Two Major Types of Glaucoma Open-Angle Glaucoma Closed-Angle Glaucoma – Most common type in North – Sharp, sudden increase in IOP due to America a blockage – Often presents without symptoms – Typical symptoms/presentation: – Chronic, slowly progressive disease – Eye pain – Primarily found in patients older – Headaches than 50 years – Decreased vision – Signs: Visual field loss, IOP normal – Medical Emergency or elevated, optic disk changes – Treated surgically – Treatment: – Also called angle-closure glaucoma – Eye drops – Surgery – More prevalent in Asia Glaucoma Treatment Goal: Decrease IOP Glaucoma treatments decrease IOP by targeting the aqueous humor (fluid in the eye) Strategies: – Reduce aqueous humor production (make less fluid) – Beta-blockers (ex. timolol) – Carbonic anhydrase inhibitors (ex. dorzolamide) – Increase aqueous humor outflow (move fluid out) – Prostaglandin analogs (ex. latanoprost) – Or, do both: often achieved with add-on treatment – Alpha-2 agonists (ex. brimonidine) Collect – Patient characteristics (eg, age, race, sex, and pregnant) – Patient history (past medical, family history of glaucoma, social, and date and results of past eye examinations) – Changes in vision – Current medications, including nonprescription agents and topically applied products, including eye drops – Objective data – IOP measurements – Disc changes and abnormalities—bilateral, symmetrical? – Visual field changes and losses Assess – If primary Closed-Angle Glaucoma is suspected, manage or refer as ophthalmologic emergency – Current medications that may contribute to or worsen glaucoma – Past history of adverse effects to agents used in the treatment of glaucoma – Identify target IOP goal based on past history and current situation Plan – Drug therapy regimen designed to achieve target IOP, including specific agent(s), dose, route, frequency, and duration; specify the continuation and discontinuation of existing therapies – Monitor IOP for target reductions (usually at least 20% reduction from baseline IOP, if not a reduction of 25% to 30%, at 4 to 6 weeks after therapy begins, and for adverse effects [eg, local intolerance or reactions, altered iris pigmentation within 2 years of treatment initiation, hypertrichosis, hyperpigmentation of lids or lashes] – Referrals to other providers when appropriate (eg, ophthalmologist) Implement – Provide patient education regarding all elements of treatment plan – Use motivational interviewing and coaching strategies to maximize adherence – Schedule follow-up, usually 4 to 6 weeks after therapy starts and every 3 to 4 months once target IOPs are achieved Follow-up: Monitor and Evaluate – Measure IOP – Optic disc and visual fields – Adverse effects/tolerability to medications – Adherence to treatment and drug administration technique – Poor adherence or nonadherence occurs in 25% to 60% of glaucoma patients. Medications Used in the Treatment of Open-Angle Glaucoma Prostaglandin (PG) analogs – Commonly used as initial treatment/often recommended as first- line therapy – Most effective medications at decreasing IOP (~30%) – Generally safe – Used once daily – Better 24-hour IOP control – Lower-cost generics available  Prostaglandin Analogs: increase aqueous humor outflow Drug Dosing Side Effects/Clinical Concerns Bimatoprost (Lumigan) 1 drop QHS WARNINGS Ocular effects: darkening of the iris, Latanoprost (Xalatan, Xelpros) Do not exceed once daily dosing; eyelid skin and eyelashes, eyelash length and number can increase + Netarsudil (Rocklatan) can decrease efficacy SIDE EFFECTS Travoprost (Travatan Z) Select products contain the Blurred vision, stinging, increased preservative benzalkonium chloride pigmentation of the iris/eyelashes, Latanoprostene bunod (Vyzulta) (BAK); remove contact lenses before eyelash growth/thickening use Tafluprost (Zioptan) CLINICAL PEARLS Travatan Z and Xelpros do not contain BAK (a different preservative is used); Bimatoprost (Latisse) is indicated can be used in patients with a past for eyelash hypotrichosis to increase reaction to BAK or dry eye eyelash growth. DO NOT use with PG analogs indicated for glaucoma Zioptan comes as 10 single-use, PF containers Latanoprost, latanoprostene bunod, and tafluprost should be stored in the refrigerator before opening; once opened, store at room temperature Naming tip:-prost = prostaglandin analog Ophthalmic beta-blockers – Commonly used as initial treatment/long history of successful use – Provides a combination of clinical efficacy and general tolerability – Decrease IOP by ~22% – A beta-blocker is preferable if the pressure is high in one eye only – Due to darkening of iris and eyelash thickening seen with PG analogs (not desirable in only one eye) Beta-Blockers: reduce aqueous humor production Drug Dosing Side Effects/Clinical Concerns Timolol 0.25% and 0.5% Timolol: 1 drop daily or BID CONTRAINDICATIONS Sinus bradycardia; heart block > 1st (Timoptic, Timoptic-XE, degree (except in patients with a Istalol, Timolol GFS, Betimol, Timoptic-XE, Timolol GFS pacemaker); cardiogenic shock; Timoptic Ocudose) (gels): daily uncompensated cardiac failure; +dorzolamide (Cosopt, Cosopt bronchospastic disease PF) Gels: shake once before use; SIDE EFFECTS +brimonidine (Combigan) wait 10 minutes after Burning, stinging, bradycardia/fatigue, administering other eye drops bronchospasm with non-selective Betaxolol (Betoptic S) before inserting gel agents, itching of the eyes or eyelids, changes in vision, increased light sensitivity Carteolol Select products contain the preservative BAK; remove CLINICAL PEARLS All are non-selective beta-blockers Levobunolol (Betagan) contact lenses before use except betaxolol; betaxolol is less likely to cause pulmonary adverse effects in patients with chronic lung disease (ex. asthma/COPD) Cosopt PF is packaged in single use containers Some products can contain sulfites, which can cause allergic reactions Adrenergic Alpha-2 Agonists – Brimonidine – Considered a second-line agent (often after a PG analog or beta blocker) or adjunctive agent – Apraclonidine – Generally used only in short term after ocular surgery – High incidence of loss of control of IOP (tachyphylaxis) – More severe and prevalent ocular allergy rate  Adrenergic Alpha-2 Agonists: increase aqueous humor outflow, reduce aqueous humor production Drug Dosing Side Effects/Clinical Concerns Brimonidine (Alphagan P) Alphagan P and Iodipine are WARNINGS +timolol (Combigan) dosed TID CNS depression: caution use +brinzolamide (Simbrinza) with heavy machinery, driving Select products contain the Apraclonidine (Iopidine) preservative BAK; remove SIDE EFFECTS contact lenses before use Sedation, dry mouth, dry nose Brimonidine (Lumify) (OTC) is indicated for ocular redness CLINICAL PEARL Alphagan P contains the preservative ‘Purite’ (the now discontinued Alphagan contained BAK) Carbonic Anhydrase Inhibitors (CAI) – Dorzolamide and Brinzolamide (Topical Agents) – Considered second line (after PG analogs and beta blockers) for monotherapy or adjunctive therapy – Reduce IOP by 15% to 26% – Brinzolamide produces more blurry vision but is less stinging than dorzolamide – Generally well-tolerated – Systemic CAI Agents – Reduce IOP by 25% to 40% – Frequently produce intolerable adverse effects – Considered third-line agents – ~ 30% to 60% of patients are able to tolerate oral CAI therapy for prolonged periods – Systemic and topical CAIs should not be used in combination  Carbonic Anhydrase Inhibitors: reduce aqueous humor production Dosing Drug Side Effects/Clinical Concerns Dorzolamide (Trusopt) Trusopt: 1 drop TID WARNINGS + timolol (Cosopt, Cosopt Sulfonamide allergy; caution due to the risk of systemic exposure and PF) Cosopt: 1 drop BID cross reactivity (especially with oral formulations) Brinzolamide (Azopt) Azopt: 1 drop TID +brimonidine (Simbrinza) SIDE EFFECTS Acetazolamide 250 mg PO 1-4 Eye drops: burning, blurred vision, blepharitis, dry eye Acetazolamide – oral, injection times per day, or 500 mg ER PO BID Oral (acetazolamide): CNS effects Methazolamide - oral (ataxia, confusion), Select ophthalmic products photosensitivity/skin rash (including contain the preservative BAK; risk of SJS), anorexia, nausea, risk of hematological toxicities remove contact lenses before use CLINICAL PEARLS Acetazolamide is used infrequently for glaucoma; it is used for the prevention and treatment of acute mountain (altitude) sickness Naming Tip:-zolamide = caution with sulfonamide allergy Rho Kinase Inhibitors – Netarsudil – FDA Approval Date: December 18, 2017 – First approved in a new class of antiglaucoma medications – Efficacy similar to beta blockers – Netarsudil/latanoprost ophthalmic solution 0.02%/0.005% (Rocklatan) – FDA Approval Date: March 13, 2019 – Combination product with PG analog – Superior IOP reduction compared to either netarsudil or latanoprost products alone – 12 month discontinuation rates: – 20.6% netarsudil/latanoprost – 23% netarsudil – 1.7% latanoprost – No generics available yet ($$$) Rho Kinase Inhibitors: increase aqueous humor outflow Dosing Drug Side Effects/Clinical Concerns Netarsudil (Rhopressa) 1 drop daily in the evening SIDE EFFECTS +latanoprost (Rocklatan) Burning/eye pain, corneal Contains the preservative BAK; disease, conjunctival remove contact lenses before hemorrhage and conjunctival use hyperemia (excess blood vessels) CLINICAL PEARLS Store in the refrigerator before opening; once opened, store at room temperature for ≤ 6 weeks Parasympathomimetic (cholinergic) agents – Use in treatment of glaucoma has decreased significantly – Local ocular adverse effects and/or frequent dosing requirements – Pilocarpine is the parasympathomimetic agent of choice – 20%-30% reduction in IOP – Patients with darkly pigmented eyes frequently require higher concentrations – Concentrations above 4% rarely improve IOP control in patients – Carbachol – Inadequate response to or intolerance of pilocarpine-> patients frequently do well – Adverse effects are similar but more frequent, constant, and severe than pilocarpine  Cholinergics: increase aqueous humor outflow DRUG DOSING SIDE EFFECTS/CLINICAL CONCERNS Carbachol (Miostat) 1-2 drops up to TID SIDE EFFECTS Poor vision at night (due to pupil constriction), corneal Pilocarpine (Isopto Carpine) Solution: 1-2 drops up to 4 clouding, burning (transient), times per day hypotension, bronchospasm, abdominal cramps/GI distress Select products contain the preservative BAK; remove CLINICAL PEARLS contact lenses before use Use with caution in patients with a history of retinal detachment or corneal abrasion  Pharmacotherapeutic – Approach Therapy is optimally started as a single agent – If medication monotherapy doesn’t sufficiently decrease IOP: – Consider switching medication therapy – Use combination therapy – May need to try several drugs or drug combinations – Prostaglandin analogs, beta blockers, brimonidine, CAI, and pilocarpine may be used in various combinations – Adequate treatment requires: – Good eye drop technique – High level of adherence – Adherence can be a major issue since Open-Angle Glaucoma often presents with no symptoms – Be sure to counsel on both proper administration technique and the importance of adherence – When drug therapy fails, is not tolerated, or is excessively complicated, surgery may be performed Glaucoma Key Concepts Reduction of IOP is Prostaglandin (PG) Patient education and essentialprogression or even (Prevents analogs are considered reinforcing adherence onset of glaucoma) the most potent topical are essential to prevent medications for reducing glaucoma progression IOP Poll Everywhere Cases References – Chapter 114 Glaucoma, DiPiro JT, Yee GC, Haines ST, Nolin TD, Ellingrod VL, Posey L. DiPiro’s Pharmacotherapy: A Pathophysiologic Approach, 12th Edition; 2023 – American Academy of Ophthalmology Glaucoma Committee. Preferred Practice Pattern Guidelines. Primary Open-Angle Glaucoma 2020. https://www.aao.org/education/preferred- practice-pattern/primary-open-angle-glaucoma-ppp Questions ?