The ABCs of Treating Glaucoma Medically

There are so many different medications used to treat Glaucoma it is often difficult to know which drugs to use first and which drugs to use if the first drug you pick doesn’t lower the patient’s IOP enough. So here are some clinical pearls to help you manage Glaucoma patients:

First, define your target pressure. This is the IOP that you want to aim for in your treatment. Your target pressure should be the IOP where your patient’s glaucoma does not progress, but since this is often difficult to determine, most clinicians try to lower IOP by 30% from their patient’s baseline IOP readings (before they start treatment).

Second, figure out what Glaucoma medication to prescribe for you patient. The following clinical pearls should help walk you through the process of selecting the right Glaucoma medication for your patient.

1. The first line treatment for Glaucoma is Prostaglandin Analogs.

These include:

  • Travatan Z /Travaprost 0.004% (Alcon, Inc. )
  • Lumigan/Bimatoprost 0.01%, 0.03% (Allergan Inc.)
  • Xalatan/Latanoprost 0.005% (Pfizer Inc.)

Prostaglandin analogs lower IOP by increasing the outflow of aqueous from the eye

Side Effects of Prostaglandin Analogs include change in eye color, stinging, blurred vision, eye redness, itching, and burning

2. If you do not get enough IOP reduction or if your patient experience side effects with Prostaglandin Analogs, try switching the patient to another class of Glaucoma medications:

A. Alpha Agonists:

  • Iopidine / Apraclonidine HCI 0.5%, 1% (Alcon, Inc.)
  • Alphagan P / Brimonidine tartrate 0.1%, 0.15% (Allergan Inc.)

Alpha Agonists lower IOP by both decreasing production of aqueous and increasing drainage.

Side effects of Alpha Agonists include burning or stinging upon instillation of the eye drop, fatigue, headache, drowsiness, dry mouth, and dry nose.

B. Beta Blockers:

  • Timolol Maleate USP / Timolol Maleate 0.5% (Akorn Ophthalmics)
  • Betoptic S / Betaxolol HCI 0.25%, 0.5% (Alcon, Inc.)
  • Betagan / Levobunolol HCI ophthalmic solution, USP 0.25%, 0.5% (Allergan Inc.)
  • OptiPranolol / Metipranolol 0.3% (Bausch & Lomb Inc)
  • Istalol / Timolol Maleate Ophthalmic Solution 0.5% (ISTA Pharmaceuticals)
  • Betimol / Timolol hemihydrate 0.25%, 0.5% (Johnson & Johnson)
  • Timoptic-XE / Timolol maleate ophthalmic gel forming solution 0.25%,   0.5% (Merck & Co. Inc.)

Beta blockers lower IOP by decreasing the production of aqueous

Side effects of Beta blockers include low blood pressure, reduced heart rate, fatigue, shortness of breath in people who have a history of asthma or other respiratory disorders, change in cardiac activity, reduced libido  and depression

C1. Carbonic Anhydrase Inhibitors (CAIs):

  •  Azopt / Brinzolamide ophthalmic suspension 1% (Alcon, Inc.)
  •  Trusopt / Dorzolamide HCI 2% (Merck & Co. Inc.)
  •  Diamox Sequels / Acetazolamide (Duramed Inc.)

CAIs decrease production of aqueous.

CAIs are available as eye drops and as pills. The pill form is an alternative for people whose glaucoma is not controlled by medication eye drops.

Side effects of the pill form include tingling or loss of strength of the hands and feet, upset stomach, mental fuzziness, memory problems, depression, kidney stones, and frequent urination

Side effects of the eye drop include stinging, burning and other eye discomfort.

C2. Cholinergics:

  • Isopto Carpine / Pilocarpine HCl 1%, 2%, 4% (Alcon, Inc.)
  • Isopto Carbachol / Carbachol 0.75%, 1.5%, 3% (Alcon, Inc.)
  • Pilopine HS Gel / Pilocarpine HCl gel 4% (Alcon, Inc.)
  • Pilo HCl Oph Soln /  Pilocarpine HCI 1%, 2%, 4% (B & L Inc.)

Cholinergics work by increasing the drainage of aqueous through the trabecular meshwork.

Side Effects of Cholinergics include constricted pupil and dim vision (especially at night or in dark areas)

C3. Combination Medications:

  • Combigan / Brimonidine Tartrate & Timolol Maleate (Allergan Inc.)
  • Cosopt / Dorzolomide HCI &   Timolol Maleate (Merck & Co. Inc.)

Combination Medications lower IOP by decreasing the production of aqueous

Side effects of Combigan include the symptoms of beta blockers and alpha agonists.

Side effects of Cosopt include burning and/or stinging of the eyes and changes in sense of taste.

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