Effectiveness and safety of switching from prostaglandin analog monotherapy to prostaglandin/timolol fixed combination therapy or adding ripasudil

Intraocular pressure-lowering effects of ripasudil on open-angle glaucoma in eyes with high myopia and pathological myopia

The aim is to study the intraocular pressure (IOP)-lowering effects of additional administration of ripasudil in open-angle glaucoma (OAG) patients including high myopia (HM) and pathological myopia (PM). Study design is retrospective cohort study. We assessed the changes in the mean IOP between the HM eyes (axial length ≧ 26.5 mm 33 eyes) and the non-HM eyes (axial length < 26.5 mm 29 eyes) at 4 and 12 weeks from baseline. We also assessed the IOP changes between the PM eyes (21 eyes) and the non-PM eyes (41 eyes). The significant IOP reduction by the ripasudil administration was observed at 4 weeks in the non-HM eyes and at 12 weeks in HM and non-HM eyes. And the IOP reduction in the HM eyes was significantly less than the non-HM eyes at 4 and 12 weeks. IOP reduction by ripasudil had statistically significant association with the baseline IOP and presence of PM. Furthermore, significant IOP reduction by the ripasudil administration was observed at 4 and 12 weeks in the non-PM eyes, but not in the PM eyes. The additional administration of ripasudil was effective in the HM eyes, but less than non-HM eyes. And the PM may negatively contribute to reducing the IOP by ripasudil.

Rho kinase inhibitor for primary open-angle glaucoma and ocular hypertension

BACKGROUND

Glaucoma is a group of optic neuropathies characterized by progressive degeneration of the retinal ganglion cells, axonal loss and irreversible visual field defects. Glaucoma is classified as primary or secondary, and worldwide, primary glaucoma is a leading cause of irreversible blindness. Several subtypes of glaucoma exist, and primary open-angle glaucoma (POAG) is the most common. The etiology of POAG is unknown, but current treatments aim to reduce intraocular pressure (IOP), thus preventing the onset and progression of the disease. Compared with traditional antiglaucomatous treatments, rho kinase inhibitors (ROKi) have a different pharmacodynamic. ROKi is the only current treatment that effectively lowers IOP by modulating the drainage of aqueous humor through the trabecular meshwork and Schlemm's canal. As ROKi are introduced into the market more widely, it is important to assess the efficacy and potential AEs of the treatment.

OBJECTIVES

To compare the efficacy and safety of ROKi with placebo or other glaucoma medication in people diagnosed with open-angle glaucoma (OAG), primary open-angle glaucoma (POAG) or ocular hypertension (OHT).

SEARCH METHODS

We used standard Cochrane methods and searched databases on 11 December 2020.

SELECTION CRITERIA

We included randomized clinical trials examining commercially available ROKi-based monotherapy or combination therapy compared with placebo or other IOP-lowering medical treatments in people diagnosed with (P)OAG or OHT. We included trials where ROKi were administered according to official glaucoma guidelines. There were no restrictions regarding type, year or status of the publication.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently screened studies, extracted data, and evaluated risk of bias by using Cochrane's RoB 2 tool.  MAIN RESULTS: We included 17 trials with 4953 participants diagnosed with (P)OAG or OHT. Fifteen were multicenter trials and 15 were masked trials. All participants were aged above 18 years. Trial duration varied from 24 hours to 12 months. Trials were conducted in the USA, Canada and Japan. Sixteen trials were funded by pharmaceutical companies, and one trial provided no information about funding sources. The trials compared ROKi monotherapy (netarsudil or ripasudil) or combination therapy with latanoprost (prostaglandin analog) or timolol (beta-blocker) with placebo, timolol, latanoprost or netarsudil. Reported outcomes were IOP and safety. Meta-analyses were applied to 13 trials (IOP reduction from baseline) and 15 trials (ocular AEs).  Of the trials evaluating IOP, seven were at low risk, three had some concerns, and three were at high risk of bias. Three trials found that netarsudil monotherapy may be superior to placebo (mean difference [MD] 3.11 mmHg, 95% confidence interval [CI] 2.59 to 3.62; I² = 0%; 155 participants; low-certainty evidence). Evidence from three trials found that timolol may be superior to netarsudil with an MD of 0.66 mmHg (95% CI 0.41 to 0.91; I² = 0%; 1415 participants; low-certainty evidence). Evidence from four trials found that latanoprost may be superior to netarsudil with an MD of 0.97 mmHg (95% CI 0.67 to 1.27; I² = 4%; 1283 participants; moderate-certainty evidence).  Evidence from three trials showed that, compared with monotherapy with latanoprost, combination therapy with netarsudil and latanoprost probably led to an additional pooled mean IOP reduction from baseline of 1.64 mmHg (95% CI -2.16 to -1.11; 1114 participants). Evidence from three trials showed that, compared with monotherapy with netarsudil, combination therapy with netarsudil and latanoprost probably led to an additional pooled mean IOP reduction from baseline of 2.66 mmHg (95% CI -2.98 to -2.35; 1132 participants). The certainty of evidence was moderate. One trial showed that,  compared with timolol monotherapy, combination therapy with ripasudil and timolol may lead to an IOP reduction from baseline of 0.75 mmHg (95% -1.29 to -CI 0.21; 208 participants). The certainty of evidence was moderate. Of the trials assessing total ocular AEs, three were at low risk, four had some concerns, and eight were at high risk of bias.  We found very low-certainty evidence that netarsudil may lead to more ocular AEs compared with placebo, with 66 more ocular AEs per 100 person-months (95% CI 28 to 103; I² = 86%; 4 trials, 188 participants). We found low-certainty evidence that netarsudil may lead to more ocular AEs compared with latanoprost, with 29 more ocular AEs per 100 person-months (95% CI 17 to 42; I² = 95%; 4 trials, 1286 participants).  We found moderate-certainty evidence that, compared with timolol, netarsudil probably led to 21 additional ocular AEs (95% CI 14 to 27; I² = 93%; 4 trials, 1678 participants). Data from three trials (1132 participants) showed no evidence of differences in the incidence rate of AEs between combination therapy with netarsudil and latanoprost and netarsudil monotherapy (1 more event per 100 person-months, 95% CI 0 to 3); however, the certainty of evidence was low. Similarly, we found low-certainty evidence that, compared with latanoprost, combination therapy with netarsudil and latanoprost may cause 29 more ocular events per 100 person-months (95% CI 11 to 47; 3 trials, 1116 participants). We found moderate-certainty evidence that, compared with timolol monotherapy, combination therapy with ripasudil and timolol probably causes 35 more ocular events per 100 person-months (95% CI 25 to 45; 1 trial, 208 participants). In all included trials, ROKi was reportedly not associated with any particular serious AEs.

AUTHORS' CONCLUSIONS

The current evidence suggests that in people diagnosed with OHT or (P)OAG, the hypotensive effect of netarsudil may be inferior to latanoprost and slightly inferior to timolol. Combining netarsudil and latanoprost probably further reduces IOP compared with monotherapy. Netarsudil as mono- or combination therapy may result in more ocular AEs. However, the certainty of evidence was very low or low for all comparisons except timolol. In general, AEs were described as mild, transient, and reversible upon treatment discontinuation. ROKi was not associated with any particular serious AEs. Future trials of sufficient size and follow-up should be conducted to provide reliable information about glaucoma progression, relevant IOP measurements and a detailed description of AEs using similar terminology. This would ensure the robustness and confidence of the results and assess the intermediate- and long-term efficacy and safety of ROKi.

Safety, efficacy, and patient selection of ripasudil in patients with uncontrolled glaucoma with maximum conventional medical therapy

Purpose:

Ripasudil hydrochloride hydrate (0.4%) is the first Rho-associated protein kinase (ROCK) inhibitor eye drop that lowers intraocular pressure (IOP) by increasing conventional aqueous outflow through the trabecular meshwork and Schlemm’s canal. We aimed to evaluate the safety and efficacy of ripasudil in patients using the maximum topical anti-glaucoma medications and with uncontrolled IOP.

Methods:

In our prospective interventional study, we enrolled 27 eligible and consenting patients (46 eyes) who presented to us between January 2021 and June 2021. Ripasudil 0.4% was added as adjunctive therapy to the ongoing glaucoma treatment. On follow-up visits at 7 days, 15 days, 1 month, 2 months, and 3 months, the visual acuity, IOP with applanation tonometer, anterior segment, and fundus were evaluated. The IOP before and after the use of ripasudil eye drops was compared by paired t-test.

Results:

Among the 27 patients, 18 were males and 9 were females. A statistically significant reduction in IOP was noted at all time durations (P < 0.00001) with the maximum reduction at 3 months with all patients achieving their target IOP. No patient developed any side effects necessitating the omission of ripasudil. The most common adverse event noted was conjunctival hyperemia (22 patients), which was mild and transient.

Conclusion:

Ripasudil showed additional IOP-lowering effect with other antiglaucoma medications and exhibited no significant side effects.

Intraocular pressure-lowering efficacy and ocular safety of Rho-kinase inhibitor in glaucoma: a meta-analysis and systematic review of prospective randomized trials

PURPOSE

To evaluate the intraocular pressure (IOP)-reducing efficacy and safety of Rho-kinase inhibitor (RKI).

METHODS

Published studies in PubMed and EMBASE were searched on March 20, 2021. Study selection and data extraction were performed according to PRISMA. Meta-analysis of the IOP-lowering effect was performed with the bivariate random-effects model, with studies categorized into 2 classes: RKI versus placebo and RKI versus another medication. The main outcome was the difference in IOP reduction between RKI and non-RKI groups. Subgroup analysis of adjunctive RKI efficacy and additional review of its major ocular adverse events (AE) were also performed.

RESULTS

Ten (2.6%) out of 391 studies were retrieved. In the RKI versus placebo class, RKI showed greater IOP reduction after 4-8 weeks (mean difference =  - 1.69 mmHg [- 2.22, - 1.16], P < 0.001). In the RKI versus another medication class, IOP reduction by RKI was noninferior to timolol 0.5% twice-daily after 4-8 weeks (mean difference = 0.39 mmHg [0.01, 0.76], P = 0.043) and 12 weeks (mean difference = 0.48 mmHg [0.11, 0.85]; P = 0.011). In the subgroup analysis, the mean difference in IOP reduction by adjunctive RKI and placebo was - 1.42 mmHg (P < 0.001). The most common ocular AE of RKI was conjunctival hyperemia (19-65%), followed by conjunctival hemorrhage (6-20%) and cornea verticillata (13-26%).

CONCLUSIONS

With a treatment duration of 1-3 months, RKI showed effective IOP reduction noninferior to timolol as monotherapy and as adjunctive therapy. Our results suggested RKI be a reliable IOP control medication; however, its higher incidence of some ocular complications should be attended to.

The Additive Effect of ROCK Inhibitor on Prostaglandin-Treated Japanese Patients with Glaucoma Indicating 15 mmHg and Under: ROCK U-15

Introduction

We aimed to evaluate the additional effects and safety of a Rho-associated protein kinase (ROCK) inhibitor, ripasudil hydrochloride hydrate, in Japanese patients with primary open-angle glaucoma (POAG) with an intraocular pressure (IOP) of at most 15 mmHg undergoing prostaglandin F_2α (FP) receptor agonist monotherapy (FP monotherapy).

Methods

In this prospective observational study, 30 Japanese patients with POAG and IOP of at most 15 mmHg (mean age 59.4 years; 10 men) who were undergoing FP monotherapy in both eyes were administered an additional dose of ripasudil hydrochloride hydrate (GLANATEC ophthalmic solution 0.4%: ripasudil) in one eye. The following factors were investigated at 1 and 3 months after the initiation of ripasudil treatment: (1) magnitude of change in IOP between the treated and contralateral untreated eyes, (2) number of treated eyes showing 20% and 30% IOP reduction, (3) IOP difference between treated and contralateral untreated eyes, and (4) safety during the treatment period. Both (1) and (3) were analyzed using the mixed-effect model for repeated measurements.

Results

The treated eyes showed significant reduction in IOP at 1 month (− 1.92 mmHg, P < 0.001) and 3 months (− 1.81 mmHg, P < 0.001). In contrast, contralateral untreated eyes did not show IOP reduction at 1 month (0.53 mmHg, P = 0.016) and 3 months (0.38 mmHg, P = 0.15). IOP reduction of − 20% and − 30% was achieved in 9 (30%) and 3 (10%) treated eyes, respectively. There were significant differences in IOP between the treated and contralateral untreated eyes at 1 month (− 2.46 mmHg, P < 0.001) and 3 months (− 2.20 mmHg, P < 0.001). Two patients experienced local adverse events (facial edema, one patient at week 1; blepharitis, one patient at 1 month); they recovered quickly after stopping ripasudil administration.

Conclusion

In patients with POAG with an IOP of at most 15 mmHg undergoing FP monotherapy, the addition of ripasudil resulted in significant IOP lowering at 1 and 3 months. Ripasudil could be used to enhance the outcome of FP monotherapy.

Trial registration

Registered UMIN ID: UMIN000030742.

[Rho kinase inhibitors as new local therapy option in primary open angle glaucoma]

BACKGROUND

In 2014 in Japan and 2017 in the USA, the Rho-kinase inhibitors were approved as a new antiglaucomatous substance group and will now be launched in Europe.

OBJECTIVE

On this occasion the current state of knowledge on Rho-kinase inhibitors is presented.

METHODS

In intensive search in PubMed the relevant experimental and clinical literature on the Rho-kinase inhibitors ripasudil and netarsudil and the combination of netarsudil and latanoprost were selected and compiled for this review.

RESULTS

The intraocular pressure lowering efficacy of ripasudil and netarsudil is in the range of the beta blocker timolol and the prostaglandin analogue latanoprost. In the fixed combination netarsudil/latanoprost the intraocular pressure reduction is greater than that of the single components and reaches a target pressure of below 15 mm Hg in 32%. Conjunctival hyperemia with 53-65% is the most common local side effect. Systemic side effects are very rare and so far there are no contraindications.

CONCLUSION

The Rho-kinase inhibitors are an interesting new introduction for glaucoma therapy, as each new pressure-lowering therapy represents an additional chance to reach the individually defined target pressure level in a glaucoma patient with local therapy; however, many of the pleiotropic effects associated with Rho-kinase inhibitors have so far only been found experimentally and will require clinical confirmation in the future.

Ripasudil Hydrochloride Hydrate in the Treatment of Glaucoma: Safety, Efficacy, and Patient Selection

Reduction of intraocular pressure (IOP) is the only reliable treatment for glaucoma that maintains the patient’s visual function throughout life, and IOP-lowering eyedrops are the mainstay of therapy. Ripasudil hydrochloride hydrate (brand name: Glanatec ophthalmic solution 0.4%; Kowa Company, Ltd., Japan) is a Rho-associated coiled-coil-containing protein kinase (ROCK) inhibitor that lowers IOP by increasing conventional aqueous outflow. Since the approval of ripasudil eyedrops in 2014, a large store of clinical data has been amassed in Japan. With regard to safety, conjunctival hyperemia is the most common adverse drug reaction (ADR) and is usually transient and mild. Blepharitis and allergic conjunctivitis are other major local ADRs. Systemic ADRs are rare, but we should be wary of allergic reactions. With regard to efficacy, ripasudil is expected to lower IOP in almost all glaucoma subtypes (including primary open-angle glaucoma, secondary glaucoma, and primary angle-closure glaucoma) and in all patterns of treatment initiation (monotherapy, combination therapy, switching therapy, and add-on therapy). However, the status of the trabecular meshwork may affect the IOP-lowering effect of ripasudil. In patient selection, current evidence-based information on the safety and efficacy of ripasudil should be fully considered. As irreversible damage to the trabecular meshwork would considerably affect efficacy, it may be better to start ripasudil treatment during an early stage of glaucoma.

Comparison of Two Combinations of Maximum Medical Therapy for Lowering Intraocular Pressure in Primary Open-angle Glaucoma

PURPOSE

We sought to compare the efficacy as well as the safety of two maximum medical therapy combinations applied to lower the intraocular pressure (IOP) in different primary open-angle glaucoma (POAG) age groups.

METHODS

This was a retrospective, consecutive case series study that included 60 eyes of 60 subjects with POAG, specifically 20 subjects aged 40 to 54 years, 21 aged 55 to 69 years, and 19 aged 70 years or older. All had been treated for at least 12 months with triple maximum medical therapy (TMT; dorzolamide/timolol, brimonidine, and latanoprost) to lower their IOP, which subsequently was changed to double maximum medical therapy (DMT, fixed drug combinations of tafluprost/timolol and brinzolamide/brimonidine). The rate of IOP change and adverse drug reactions were compared amongst the three age groups.

RESULTS

The mean IOP change at three months after converting from TMT to DMT was -0.65 ± 1.42 mmHg (-3.84% ± 9.31%) among the overall study group, but this finding was not statistically significant (p = 0.108). In the 40 to 54 years and 55 to 69 years groups, the mean IOP change rates were +0.29 ± 0.96 mmHg (+2.40% ± 6.85%, p = 0.087) and -0.50 ± 0.99 mmHg (-3.05% ± 6.40%, p = 0.084) respectively. In the 70 years or older group, the mean IOP change, interestingly, was -1.80 ± 1.46 mmHg (-11.29% ± 9.31%, p < 0.001) and nine (47.4%) of the 19 subjects showed additional IOP reductions of 10% or more after converting from TMT to DMT. In all three age groups, the incidence rate of dry eye was significantly lower for DMT than for TMT (p = 0.031).

CONCLUSIONS

In POAG patients, DMT was proven to be both effective and safe for lowering the IOP, especially in those 70 years or older group, when compared with the TMT protocol.