Efficacy and safety of ketorolac tromethamine 0.5% and levocabastine 0.05%: a multicenter comparison in patients with seasonal allergic conjunctivitis

Development and in vitro-in vivo evaluation of ocular insert containing ketorolac tromethamine and moxifloxacin hydrochloride

PURPOSE

Conjunctivitis is a common eye disorder that causes swelling and inflammation of the conjunctiva. Topical dosage form containing antibiotics and non-steroidal anti-inflammatory drugs are prescribed for the treatment and in order to overcome problems of conventional dosage forms the present study aims to develop an ocular insert containing moxifloxacin HCl and ketorolac tromethamine.

METHODS

Insert was prepared by a solvent casting method by taking different polymers PVA, PVP K-30, and a combination of both as film-forming polymer, and glycerol as a plasticizer and characterized by various parameters like thickness, folding endurance, pH, swelling index, drug content, mechanical properties, in vitro and in vivo release study.

RESULTS

The formulation prepared by a combination of both polymers demonstrated significantly improved properties including % elongation, tensile strength, swelling index, drug content and drug release compared to the formulation made with single polymer. The in vitro release data indicated that the batch R8 exhibited sustain release of drug (85% release in 10 hr) and following the Higuchi model for release kinetics. In vivo, study in rabbit eyes revealed the sustained release of the drug up to 16 hr with a good correlation between in vitro and in vivo release data.

CONCLUSION

From the study, it can be concluded that the developed ocular insert can be a promising formulation for rational therapy of conjunctivitis.

Comparative analysis of safety and efficacy of Alcaftadine 0.25%, Olopatadine hydrochloride 0.2% and Bepotastine besilate 1.5% in allergic conjunctivitis

Purpose:

To compare the efficacy and safety of Alcaftadine 0.25%, Olopatadine hydrochloride 0.2%, and Bepotastine besilate 1.5% ophthalmic solutions in the treatment of allergic conjunctivitis.

Methods:

This is a prospective, observer-masked, comparative study of 180 patients with mild to moderate allergic conjunctivitis, randomized into three groups of 60 patients each. Each group was assigned to be treated with one of the three treatment options namely Alcaftadine 0.25%, Olopatadine hydrochloride 0.2% and Bepotastine besilate 1.5% ophthalmic solutions. Patients were followed-up at regular intervals with relief and resolution of symptoms and signs noted using Total Ocular Scoring System (TOSS) and hyperaemia scale.

Results:

All three topical medications were effective in resolving symptoms of the patients with mild to moderate allergic conjunctivitis. Baseline mean TOSS scores for Alcaftadine group, Olopatadine group and Bepotastine besilate group were (7.68±2.32), (7.65±2.32) and (7.45±2.27) respectively as compared to the corresponding TOSS scores on 14^th Day (4^th visit) which were (0.2 ± 0.43), (0.4 ± 0.56) and (0.1 ± 0.36) respectively. The resolution of symptoms in the Bepotastine and Alcaftadine groups was significantly profound as compared to the Olopatadine group (p = 0.008). Bepotastine and Alcaftadine groups significantly reduced allergic conjunctivitis symptoms compared to Olopatadine group (p = 0.008).

Conclusion:

All three topical ophthalmic medications used in the study are safe and effective in the treatment of allergic conjunctivitis. However, Bepotastine and Alcaftadine appear to outweigh Olopatadine in resolving the symptoms of allergic conjunctivitis.

Observer-masked trial comparing efficacy of topical olopatadine (0.1%), bepotastine (1.5%), and alcaftadine (0.25%) in mild to moderate allergic conjunctivitis

Purpose:

With increasing environmental pollution, the incidence of allergic conjunctivitis is increasing. Newer anti-allergic medications with combined anti-histaminic and mast cell stabilization action can help reducing the use of topical steroids for milder form of disease. There is no study directly comparing olopatadine (0.1%), bepotastine (1.5%), and alcaftadine (0.25%) for mild to moderate allergic conjunctivitis cases. Hence, we decided to methodically study the efficacy of three topical medications.

Methods:

Prospective, observer-masked clinical trial enrolled 45 patients with 15 patients in each of the three groups. Patients with mild to moderate allergic conjunctivitis were sequentially assigned to respective groups, and relief of symptoms and signs were noted upto 1-month follow-up.

Results:

All three topical medications faired almost equally in resolving symptoms of the patients with mild to moderate allergic conjunctivitis, and most of them reported complete relief after 1 week of use of medication. Few cases with limbal or palpebral papillae reported symptomatic relief after use of medication, but the resolution of these signs was not noted in all three groups.

Conclusion:

We concluded similar efficacy of three medications in relieving symptoms and inefficacy in regressing palpebral and limbal papillae in cases of allergic conjunctivitis.

Ocular itch associated with allergic conjunctivitis: latest evidence and clinical management

Allergic conjunctivitis is one of the most common allergic conditions worldwide. Its incidence is increasing due to changing climate, pollution, increased pollen loads, and the subject's heightened immunological sensitivity in response to these environmental changes. The pathophysiology predominantly involves immunoglobulin E-related mast-cell activation, with release of histamine and other mediators contributing to the propagation of the response by calling in other immune cells and further inflammation. This article presents the evolution of ocular allergy treatments, from vasoconstrictors, to antihistamines and mast-cell stabilizers, to the dual-acting agents, as well as corticosteroid and immunomodulatory options. Future targets for allergy treatment are also discussed.

Conjunctivitis: a systematic review of diagnosis and treatment

IMPORTANCE

Conjunctivitis is a common problem.

OBJECTIVE

To examine the diagnosis, management, and treatment of conjunctivitis, including various antibiotics and alternatives to antibiotic use in infectious conjunctivitis and use of antihistamines and mast cell stabilizers in allergic conjunctivitis.

EVIDENCE REVIEW

A search of the literature published through March 2013, using PubMed, the ISI Web of Knowledge database, and the Cochrane Library was performed. Eligible articles were selected after review of titles, abstracts, and references.

FINDINGS

Viral conjunctivitis is the most common overall cause of infectious conjunctivitis and usually does not require treatment; the signs and symptoms at presentation are variable. Bacterial conjunctivitis is the second most common cause of infectious conjunctivitis, with most uncomplicated cases resolving in 1 to 2 weeks. Mattering and adherence of the eyelids on waking, lack of itching, and absence of a history of conjunctivitis are the strongest factors associated with bacterial conjunctivitis. Topical antibiotics decrease the duration of bacterial conjunctivitis and allow earlier return to school or work. Conjunctivitis secondary to sexually transmitted diseases such as chlamydia and gonorrhea requires systemic treatment in addition to topical antibiotic therapy. Allergic conjunctivitis is encountered in up to 40% of the population, but only a small proportion of these individuals seek medical help; itching is the most consistent sign in allergic conjunctivitis, and treatment consists of topical antihistamines and mast cell inhibitors.

CONCLUSIONS AND RELEVANCE

The majority of cases in bacterial conjunctivitis are self-limiting and no treatment is necessary in uncomplicated cases. However, conjunctivitis caused by gonorrhea or chlamydia and conjunctivitis in contact lens wearers should be treated with antibiotics. Treatment for viral conjunctivitis is supportive. Treatment with antihistamines and mast cell stabilizers alleviates the symptoms of allergic conjunctivitis.

Allergic conjunctivitis: a comprehensive review of the literature

Ocular allergy represents one of the most common conditions encountered by allergists and ophthalmologists. Allergic conjunctivitis is often underdiagnosed and consequently undertreated. Basic and clinical research has provided a better understanding of the cells, mediators, and immunologic events, which occur in ocular allergy. New pharmacological agents have improved the efficacy and safety of ocular allergy treatment. An understanding of the immunologic mechanisms, clinical features, differential diagnosis, and treatment of ocular allergy may be useful to all specialists who deal with these patients. The purpose of this review is to systematically review literature underlining all the forms classified as ocular allergy: seasonal allergic conjunctivitis, perennial allergic conjunctivitis, vernal keratoconjunctivitis, atopic keratocongiuntivitis, contact allergy, and giant papillary conjunctivitis.

Topical non-steroidal anti-inflammatory drugs in allergic conjunctivitis: meta-analysis of randomized trial data

PURPOSE

To assess the effect of topical Non-Steroidal Anti Inflammatory drugs in the treatment of allergic conjunctivitis.

METHOD

Systematic Review.

DATA SOURCES AND STUDY SELECTION

Reports of comparative randomized trials of topical NSAIDs and placebo identified by searches of Medline, Embase, the Cochrane Register of Controlled Trials.

DATA EXTRACTION AND SYNTHESIS

Two reviewers assessed trials for eligibility and quality and extracted data independently. Data were synthesized (random effects model) and results expressed results for dichotomous outcomes as relative risk and continuous outcomes as weighted mean difference. Sensitivity analysis was used to examine potential heterogeneity by differences in study quality.

RESULTS

Eight studies incorporating 712 patients were included. The difference between the decrease in allergic sign and symptom score for NSAID treatment compared to placebo was between 4 and 19 percentage points. Topical NSAIDs produced significantly greater relief for conjunctival itching (cardinal symptom) than did placebo (combined standardized mean difference -0.54 (p < 0.001; 95% confidence interval -0.84 to -0.24). The results for the other allergic symptoms: ocular burning/pain, eyelid swelling, photophobia and foreign sensation were not significant. Topical NSAIDs produced significantly greater reduction of conjunctival injection than did placebo (combined standardized mean difference -0.51 (p = 0.03; 95% confidence interval -0.97 to -0.05). Topical NSAIDs did not reduce the allergic signs of conjunctival chemosis, conjunctival mucus, eyelid swelling and corneal disturbance. Topical NSAIDs had a significantly higher rate of burning/stinging on application of medication compared to placebo (P < 0.0001; odds ratio 3.97 (95% CI 2.67 to 5.89).

CONCLUSION

This meta-analysis confirms that topical NSAID are significantly more effective at relieving the cardinal symptom: conjunctival itching and improving the cardinal sign: conjunctival injection than placebo treatment. A systematic review comparing topical NSAIDs to topical antihistamines/mast cell stabilizers in treatment of allergic conjunctivitis is warranted as this will compare the topical NSAIDs to current therapeutic guidelines.

The role of NSAIDs in the management of postoperative ophthalmic inflammation

Recent advances in cataract surgery, such as phacoemulsification, small-incision surgery and advances in foldable intraocular lenses, have resulted in the decrease of physical trauma associated with cataract surgery. The decrease in the physical surgical trauma decreases the release of prostaglandins, which are the main players in postoperative ocular inflammation. However, postoperative inflammation continues to be a cause of patient discomfort, delayed recovery and, in some cases, suboptimal visual results. Left untreated, this inflammation might interfere with patients' rehabilitation and/or contribute to the development of other complications, such as cystoid macular oedema.NSAIDs are commercially available, in topical or systemic formulations, for the prophylaxis and treatment of ocular conditions. Topically applied NSAIDs are commonly used in the management and prevention of non-infectious ocular inflammation and cystoid macular oedema following cataract surgery. They are also used in the management of pain following refractive surgery and in the treatment of allergic conjunctivitis. Despite their chemical heterogeneity, all NSAIDs share the similar therapeutic property of inhibiting the cyclo-oxygenase enzyme. The appeal of using NSAIDs in the treatment of ocular inflammation hinges on the complications associated with corticosteroids, the other commonly used therapy for ophthalmic inflammation.

Efficacy of Low Concentrations of Ketorolac Tromethamine in Animal Models of Ocular Inflammation

PURPOSE

To determine if topical ophthalmic application of ketorolac tromethamine concentrations below 0.5% can block the biochemical and physiological processes associated with chemically induced ocular inflammation in rabbits.

METHODS

Ocular inflammation was induced in rabbits by intravenous (i.v.) injection of endotoxin (2.5 microg/kg) isolated from Salmonella typhimurium, or by a topical application of arachidonic acid (1.0%). The effect of ketorolac (at concentrations ranging from 0.001%-0.5%) on ocular inflammation was determined by measuring changes in the blood-aqueous barrier, using fluorophotometry (dextran-isothiocyanate-fluorescein; FITC-dextran 2%) and by measuring changes in aqueous humor protein concentrations. Changes in aqueous humor prostaglandin E(2) (PGE(2)) concentrations were also measured.

RESULTS

Ketorolac 0.01%-0.5% produced substantial decreases in endotoxin-induced fluorescein leakage into the aqueous humor. The decrease produced by ketorolac 0.1% was comparable to that produced by ketorolac 0.5%. Ketorolac 0.1%-0.5% produced substantial decreases in endotoxin-induced increases in prostaglandin concentrations in the aqueous humor, and in arachidonic acid-induced protein leakage into the aqueous humor.

CONCLUSIONS

Topical application of ketorolac concentrations as low as 0.01%-0.1% significantly reduce chemically induced ocular inflammation in rabbits.

Efficacy and safety of ketotifen eye drops in the treatment of seasonal allergic conjunctivitis

BACKGROUND

Ketotifen blocks histamine H(1) receptors, stabilises mast cells, and prevents eosinophil accumulation. These multiple, pharmacological mechanisms provided the rationale for assessing the efficacy and safety of ketotifen 0.025% eye drops in subjects with seasonal allergic conjunctivitis (SAC) in an environmental setting.

METHODS

This was a double masked, randomised, multicentre trial conducted in Australia. Subjects were randomly assigned to ketotifen fumarate 0.025% ophthalmic solution, placebo (as vehicle), or levocabastine hydrochloride 0.05% ophthalmic suspension, twice daily in each eye for a 4 week period. Subjects were assessed at follow up (days 5-8) and termination (days 25-31) visits. The primary efficacy variable was the responder rate, based on the subjects' assessment of global efficacy at the follow up visit.

RESULTS

519 subjects were randomised to treatment. At the follow up visit, the responder rate, based on subjects' assessment of global efficacy, was significantly greater in the ketotifen group (49.5%) than in the placebo group (33.0%) for subjects with a positive diagnostic test for pollen allergy (p = 0.02). The investigators' assessment of responder rates also showed that ketotifen was superior to placebo (p = 0.001). Ketotifen produced a significantly better outcome than levocabastine (p<0.05) for relief of signs and symptoms of SAC, at both the follow up and the termination visit. The type and frequency of adverse events were similar across treatment groups.

CONCLUSIONS

In an environmental setting, ketotifen fumarate 0.025% ophthalmic solution was well tolerated and effective in reducing the signs and symptoms of SAC, and in preventing their recurrence. Ketotifen consistently showed the best efficacy in comparison with both placebo and levocabastine. These results indicate that ketotifen eye drops are a valuable treatment option for this condition.

Topical immunopharmacology of ocular allergies

PURPOSE OF REVIEW

To review the histamine-1 receptor antagonists, mast cell blockers and natural agents with such actions that can be used for the topical treatment of ocular allergies.

RECENT FINDINGS

Increasing evidence indicates that some histamine-1 receptor antagonists have additional actions to inhibit secretion of inflammatory mediators, especially cytokines, from ocular mast cells and other cell types. Emerging information suggests that such actions may be through regulation of intracellular calcium ion levels of NF-kappaB activation.

SUMMARY

A number of available drugs and natural non-prescription agents may have anti-histaminic and anti-inflammatory actions.

Pemirolast potassium 0.1% ophthalmic solution is an effective treatment for allergic conjunctivitis: a pooled analysis of two prospective, randomized, double-masked, placebo-controlled, phase III studies

Patients with allergic conjunctivitis may experience several debilitating symptoms, particularly ocular itching. The objective of this study was to evaluate the efficacy and safety of pemirolast potassium 0.1% ophthalmic solution (Alamast trade mark ), a novel mast-cell stabilizer, for preventing ocular manifestations of seasonal allergic conjunctivitis. A pooled analysis was performed of data derived from 2 prospective, randomized, double-masked, placebo-controlled, multicenter phase III clinical trials of pemirolast potassium 0.1% in patients with a history of allergic conjunctivitis. Patients having a positive bilateral response to conjunctival allergen challenge (CAC) with ragweed antigen (N = 274) were randomized to receive pemirolast potassium 0.1% or placebo QID, beginning approximately 1-2 weeks before the onset of ragweed season and continuing until after the first killing frost (12-17 weeks duration). Patients recorded their daily evaluations of ocular itching in a diary. After the allergy season, patients underwent a second CAC. Evaluable patients (n = 265) recorded a total of 21,491 patient-days of ocular itching data during allergy season. In every 7-day or 14-day period, patients treated with pemirolast potassium 0.1% reported more days without any ocular itching compared with patients receiving placebo. Differences favoring pemirolast potassium 0.1% were statistically significant in 63% (10/16) of all 7-day periods (p < or = 0.046) and 88% (7/8) of all 14-day periods (p < or = 0.016). After the allergy season, pemirolast potassium 0.1% was significantly superior to placebo in relieving CAC-induced ocular itching, with relief occurring as early as 3 minutes after allergen challenge (p < or = 0.034). Pemirolast potassium 0.1% was well tolerated and had a safety profile similar to that of placebo. In conclusion, pemirolast potassium 0.1% is effective and safe in preventing ocular itching in patients with allergic conjunctivitis during allergy season.

Ocular allergy guidelines: a practical treatment algorithm

The treatment of ocular allergy requires a better understanding of the spectrum of clinical disorders involving various components of the immune system, and of interactions at the conjunctival surface. The immune response focuses primarily on the different levels of activity of Th2 lymphocytes and various other immune cells associated with allergic disorders, including mast cells, eosinophils, fibroblasts, and epithelial and endothelial cells. Ocular allergic disorders include seasonal allergic conjunctivitis (SAC), perennial allergic conjunctivitis (PAC), vernal keratoconjunctivitis (VKC), giant papillary conjunctivitis (GPC) and atopic keratoconjunctivitis (AKC), which, through immunopathological and molecular immunological techniques, can all be better appreciated as being part of a larger spectrum of an atopic disease state. In SAC, pathological changes, such as increased mast-cell activation, the presence of migratory inflammatory cells, and early signs of cellular activation at the molecular level, are minimal. In PAC, these changes are more pronounced in line with the increased duration of allergenic stimulation. In more chronic forms of allergic conjunctivitis, such as VKC in children and AKC in adults, the following changes are evident: a persistent state of mast cell, eosinophil and lymphocyte activation; noted switching from connective-tissue to mucosal-type mast cells; increased involvement of corneal pathology; and follicular development and fibrosis. The treatment of acute and more chronic forms of allergic conjunctivitis has focused in the past on symptomatic relief of symptoms, but with a better understanding of the mechanisms involved we can now provide interventional therapeutic strategies and symptomatic relief. Our advances in the basic understanding of these conditions are providing the foundation for guidelines that improve the ocular health of patients with ocular allergies.

Advances in ocular allergy: basic mechanisms, clinical patterns and new therapies

Ocular allergy presents unsolved mysteries in molecular and cellular mechanisms, and at the same time continues to challenge ophthalmologists daily in a wide array of disease forms. The recent understanding of the key role of the T helper type 2 cytokines, adhesion molecules and chemokines may provide future avenues for pharmacological targeting of releasable inflammatory mediators. More potent topical mast cell stabilizers and H1 receptor antagonists have become commercially available for the management of the prevalent and benign forms of allergic conjunctivitis. Immunostimulatory DNA sequences present an innovative and promising route for the treatment of ocular allergy, but clinical studies are needed to demonstrate their efficacy in humans. Surgical methods are suggested to reconstruct the ocular surface in the sight-threatening diseases vernal keratoconjunctivitis and atopic keratoconjunctivitis. This review presents an update of the major advances in both the basic mechanisms and clinical and therapeutic aspects of ocular allergic diseases that were reported during the past year.