Therapeutics

Topical Glaucoma Treatments — Educating about Costs to Optimize Benefit

PART TWO: An overview of medical options for glaucoma patients.

By David D. Richardson, MD

One of the benefits of modern glaucoma treatment is the variety of pharmacologic options now available to our patients with this condition. That benefit, however, is not without cost. Patients face a monetary cost, a cost of time (depending on frequency of dosing and inconvenience) and a cost in terms of side effects. (Part one of this series, which appeared in the January/February issue of OP, page 26, explained how to discuss glaucoma therapies with patients.)

Brand vs. Generic (Monetary Cost)

The monetary cost of any prescription therapy can be burdensome to the patient. Many patients with glaucoma also have other health issues where glaucoma therapy may represent a small fraction of the monthly medications cost. As branded glaucoma drops often retail for more than $80 per month, it is important to recognize the availability of generics (which can retail for as little as $4).

Dosing (Time and Inconvenience Cost)

“Time is money,” or so we’re told. Even if the majority of your glaucoma patients are retired, when someone must take time out of their day to administer medications, it adds a “lifestyle cost.” This cost is real and is backed up by multiple studies indicating that as the dosage frequency goes up, compliance plummets. It is important to assess whether the patient can afford the demands of twice or thrice a day dosing.

Side Effects (Quality of Life Cost)

Your patients will often forgive you for prescribing something with which they can neither afford nor handle the dosing schedule. However, if you do not inform them of potential side effects, don’t expect them to be so understanding. Money and time are simply surrogates for quality of life. After all, isn’t a high quality of life what we’re all striving for?

Avoid Sticker Shock

Nobody likes surprises. Well, that may not be true for children under the age of eight, but it tends to be a good rule of thumb for our older patients with glaucoma. Surprise them with an unusually fast office visit, not the costs of glaucoma treatment.

To prescribe any treatment to our patients without considering these costs will increase the risk of treatment failure. It is far better to educate our patients about these costs before they leave. Otherwise, when patients meet unexpected costs, they are likely to stop or decrease treatment. Below is a brief summary of these “costs” for each of the commonly used classes of glaucoma medications.

BETA-BLOCKERS

I. Nonselective

• Timolol (most commonly used)• Carteolol
• Levobunolol
• Metipranolol

II. “Cardioselective” (reduced respiratory side effects)

• Betaxolol
• Generic Available: Yes

Dosing: once a day (usually in the morning)

Side Effects: Shortness of breath, hypotension (low blood pressure), bradycardia (low heart rate), fatigue, depression, and rarely death. These adverse side effects can manifest themselves months or even years after initiation of treatment.

Interesting Fact: “Crossover effect” can result in IOP lowering not only in the eye that is being treated, but in the non-treated eye also.

ADRENERGIC AGONISTS

• Brimonidine (most commonly used)• Apraclonidine (primarily used prior to laser treatments)
• Generic Available: Yes

Dosing: twice daily (though more effective TID)

Side Effects: Follicular conjunctivitis, oral dryness, sedation, drowsiness, headache, fatigue. Central nervous system depression (can be life threatening in infants and toddlers).

Interesting Fact: Evidence is mounting that this drop has a “neuroprotective” effect that may protect the optic nerve independent of IOP lowering effect.

TOPICAL CARBONIC ANHYDRASE INHIBITORS

• Brinzolamide• Dorzolamide
• Generic Available: Yes (for Dorzolamide)

Dosing: Two to three times daily (BID-TID)

Side Effects: Ocular stinging (worse with dorzolamide)

Interesting Fact: The carbonic anhydrase enzyme is used by the corneal endothelium to pump out fluid. Therefore, this is not a good choice of glaucoma therapy in people with corneal diseases such as Fuch’s dystrophy.

ORAL CARBONIC ANHYDRASE INHIBITORS

• Acetazolamide• Methazolamide
• Generic Available: Yes (but not for BID dosing)

Dosing: Two to four times a day (BID-QID)

Side Effects: Dizziness, tingling of extremities, frequent urination, metabolic acidosis, aplastic anemia (life threatening)

Interesting Fact: This medication is sometimes used to treat macular edema (such as that associated with retinitis pigmentosa)

PROSTAGLANDIN ANALOGS

• Bimatoprost• Latanoprost
• Travoprost
• Tafluprost
• Generic Available: Yes (for Latanoprost only)

Dosing: Once a day (usually at night, QHS)

Side Effects: Lash growth (not always in a cosmetically pleasing manner), iris color change, darkening of the periocular skin, “tightening” and hollowing out of the periocular connective tissue (Prostaglandin associated periorbitopathy), nocturnal headaches (rare)

Interesting Fact: Prostaglandins work better once a day morose than twice daily.

MIOTIC AGENTS

• Pilocarpine• Generic Available: Yes

Dosing: Four times a day (QID)

Side Effects: Headache, decreased vision, retinal detachment

Interesting Fact: Pilocarpine can occasionally result in improved vision as pupil constriction results in a “pinhole” effect (similar to what we see in the office when testing vision). OP

Dr. Richardson is an ophthalmologist practicing in Southern California. He is an adamant believer that successful treatment depends on a strong foundation of patient education. As such, he has authored a book www.Cataract-Book.com and blog www.About-Eyes.com about cataract surgery, as well as a Web site about glaucoma treatment www.New-Glaucoma-Treatments.com.