Ophthalmic Drugs as Part of Polypharmacy in Nursing Home Residents with Glaucoma

Association of Systemic Medication Use with Glaucoma and Intraocular Pressure: The European Eye Epidemiology Consortium

PURPOSE

To investigate the association of commonly used systemic medications with glaucoma and intraocular pressure (IOP) in the European population.

DESIGN

Meta-analysis of 11 population-based cohort studies of the European Eye Epidemiology Consortium.

PARTICIPANTS

The glaucoma analyses included 143 240 participants and the IOP analyses included 47 177 participants.

METHODS

We examined associations of 4 categories of systemic medications-antihypertensive medications (β-blockers, diuretics, calcium channel blockers [CCBs], α-agonists, angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers), lipid-lowering medications, antidepressants, and antidiabetic medications-with glaucoma prevalence and IOP. Glaucoma ascertainment and IOP measurement method were according to individual study protocols. Results of multivariable regression analyses of each study were pooled using random effects meta-analyses. Associations with antidiabetic medications were examined in participants with diabetes only.

MAIN OUTCOME MEASURES

Glaucoma prevalence and IOP.

RESULTS

In the meta-analyses of our maximally adjusted multivariable models, use of CCBs was associated with a higher prevalence of glaucoma (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.08 to 1.39). This association was stronger for monotherapy of CCBs with direct cardiac effects (OR, 1.96; 95% CI, 1.23 to 3.12). No other antihypertensive medications, lipid-lowering medications, antidepressants, or antidiabetic medications were associated with glaucoma. Use of systemic β-blockers was associated with a lower IOP (β coefficient, -0.33 mmHg; 95% CI, -0.57 to -0.08 mmHg). Monotherapy of both selective systemic β-blockers (β coefficient, -0.45 mmHg; 95% CI -0.74 to -0.16 mmHg) and nonselective systemic β-blockers (β coefficient, -0.54 mmHg; 95% CI, -0.94 to -0.15 mmHg) was associated with lower IOP. A suggestive association was found between use of high-ceiling diuretics and lower IOP (β coefficient, -0.30 mmHg; 95% CI, -0.47 to -0.14 mmHg) but not when used as monotherapy. No other antihypertensive medications, lipid-lowering medications, antidepressants, or antidiabetic medications were associated with IOP.

CONCLUSIONS

We identified a potentially harmful association between use of CCBs and glaucoma prevalence. Additionally, we observed and quantified the association of lower IOP with systemic β-blocker use. Both findings potentially are important, given that patients with glaucoma frequently use systemic antihypertensive medications. Determining causality of the CCB association should be a research priority.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Clinico-cytological analysis of conjunctiva and ocular surface symptoms of patients on topical anti-glaucoma medications attending Lagos University Teaching Hospital, Lagos, Nigeria: A case-control study

Background

The long-term use of topical anti-glaucoma medications is often associated with ocular surface toxicity that can affect the patient's drug compliance and quality of life. This study assessed the effect of these medications, using cytological changes of the conjunctiva and ocular surface symptoms.

Materials and Methods

This was a clinic-based, case-control study that was conducted at the Lagos University Teaching Hospital that compared glaucoma patients on topical medications with age-sex-matched controls. The controls were non-glaucoma patients, who were not on any topical ocular medications at least 6 months prior to the study. The Ocular Surface Disease Index (OSDI) questionnaire was used to assess ocular surface symptoms. Schirmer's I test, tear film break-up time (TBUT) test and corneal fluorescein staining of the ocular surface were used for ocular surface disease (OSD) assessment and conjunctival impression cytology (CIC) for histological assessment and grading.

Results

Six hundred and ninety-six eyes of 348 respondents, 174 cases and 174 controls, were assessed for OSD. The mean ages of the case and control groups were 56.3 ± 12.9 years and 55.5 ± 13.2 years, respectively, with no statistical difference (P = 0.589). All ocular parameters assessed were significantly abnormal in the case group compared to the control group. The use of topical anti-glaucoma medications was significantly associated with abnormal TBUT (P < 0.001), Schirmer's test (P < 0.001), ocular surface staining (P < 0.001), CIC (P < 0.001) and OSDI scores (P = 0.001). A significant association was seen between abnormal TBUT and the number of medications (P = 0.044, odds ratio [OR] =0.79, 95% confidence interval [CI]: 0.44-1.14), between abnormal ocular surface staining and duration of anti-glaucoma medications usage (P = 0.0104, OR = 1.2, 95% CI: 1.04-1.43) and between abnormal CIC and the duration of anti-glaucoma medications (P = 0.0007, OR = 0.7, 95% CI: 0.59-0.86).

Conclusion

The study demonstrates that prolonged use of topical anti-glaucoma medications may be associated with damage to the ocular surface structures.

The Multifarious Effects of Various Glaucoma Pharmacotherapy on Corneal Endothelium: A Narrative Review

Corneal endothelium is a single cell layer that is mainly responsible for maintaining corneal clarity. Endothelial damage secondary to toxicity, stress, or genetic predisposition are common and in conjunction with the low regenerative ability of the cells, making their preservation critical for maintaining visual acuity. Patients with glaucoma, who are estimated to be close to 80 million worldwide, have a plethora of reasons for developing endothelial damage, being exposed to a spectrum that extends from various medical and surgical interventions to the disease itself. The wide spectrum of glaucoma pharmacotherapy that has been recently extended by addition of newer classes of medications has been the focus of extensive research on its effects on corneal endothelium. Both basic and clinical research have attempted to shine a light on the complex mechanisms associated with the effects of glaucoma medication on corneal endothelium and to answer the important question as to whether these findings are clinically significant. The aim of this review is to summarize and present current literature of the various findings, both from in vivo and in vitro studies that have focused on the complex relationship between different classes of glaucoma medication and their effect on corneal endothelium.

Real-World Analysis on the Characteristics, Therapeutic Paths and Economic Burden for Patients Treated for Glaucoma in Italy

This real-world analysis was performed on administrative databases to evaluate characteristics, therapies, and related economic burden of glaucoma in Italy. Adults with at least 1 prescription for ophthalmic drops (ATC class S01E: antiglaucoma preparations, miotics) during data availability period (January 2010-June 2021) were screened, then patients with glaucoma were included. First date of ophthalmic drops prescription was the index date. Included patients had at least 12 months of data availability before index-date and afterwards. Overall, 18,161 glaucoma-treated patients were identified. The most frequent comorbidities were hypertension (60.2%), dyslipidemia (29.7%) and diabetes (17%). During available period, 70% (N = 12,754) had a second-line therapy and 57% (N = 10,394) a third-line therapy, predominantly ophthalmic drugs. As first-line, besides 96.3% patients with ophthalmic drops, a small proportion reported trabeculectomy (3.5%) or trabeculoplasty (0.4%). Adherence to ophthalmic drops was found in 58.3% patients and therapy persistence reached 78.1%. Mean total annual cost per patient was €1,725, mostly due to all-cause drug expenditure (€800), all-cause hospitalizations (€567) and outpatient services (€359). In conclusion, glaucoma-treated patients were mostly in monotherapy ophthalmic medications, with an unsatisfying adherence and persistence (<80%). Drug expenditures were the weightiest item among healthcare costs. These real-life data suggest that further efforts are needed to optimize glaucoma management.

Individualized Beta-Blocker Treatment for High Blood Pressure Dictated by Medical Comorbidities: Indications Beyond the 2018 European Society of Cardiology/European Society of Hypertension Guidelines

Several hypertension guidelines have removed beta-blockers from their previous position as first-choice drugs for the treatment of hypertension. However, this downgrading may not be justified by available evidence because beta-blockers lower blood pressure as effectively as other major antihypertensive drugs and have solid documentation in preventing cardiovascular complications. Suspected inconveniences of beta-blockers such as increased risk of depression or erectile dysfunction may have been overemphasized, while patients with chronic obstructive pulmonary disease or peripheral artery disease, that is, conditions in which their use was previously restricted, will benefit from beta-blocker therapy. Besides, evidence that from early to late phases, hypertension is accompanied by activation of the sympathetic nervous system makes beta-blockers pathophysiologically an appropriate treatment in hypertension. Beta-blockers have favorable effects on a variety of clinical conditions that may coexist with hypertension, making their use either as specific treatment or as co-treatment potentially common in clinical practice. Guidelines typically limit recommendations on specific beta-blocker use to cardiac conditions including angina pectoris, postmyocardial infarction, or heart failure, with little or no mention of the additional cardiovascular or noncardiovascular conditions in which these drugs may be needed or preferred. In the present narrative review, we focus on multiple additional diseases and conditions that may occur and affect patients with hypertension, often more frequently than people without hypertension, and that may favor the choice of beta-blocker. Notwithstanding, beta-blockers represent an in-homogenous group of drugs and choosing beta-blockers with documented effect in prevention and treatment of disease is important for first choice in guidelines.

Prevalence of Eye Conditions, Utilization of Eye Health Care Services, and Ophthalmic Medications After Entering Residential Aged Care in Australia

Purpose

This study aims to evaluate the burden and trends of eye diseases, utilisation of eye health care services, and ophthalmic medications among older people living in residential aged care facilities in Australia.

Methods

A cross-sectional study was conducted using data from the Registry of Senior Australians. Individuals aged ≥65 years who entered permanent residential aged care facilities between 2008 and 2015 were included. The prevalence (95% confidence interval [CI]) of eye diseases by year, eye health care services, and ophthalmic medication use within a year of entry into the service were evaluated. Poisson regression models estimated adjusted rate of change using prevalence ratio (PR) by age, sex, state, and frailty scores.

Results

Of the 409,186 people studied, 43.6% (N = 178,367) had an eye condition. Of the total cohort, 32.9% (N = 134,566) had chronic eye conditions and 19.7% (N = 80,661) had an acute eye condition. Common chronic eye conditions were glaucoma (13.6%, N = 55,830), cataract (8%, (N = 32,779), blindness (4.5%, N = 18,856), and poor vision (10.3%, N = 42,245). Prevalence of any eye condition (2008: 42.7%, 95% CI = 42.2%-43.2% and 2015: 41.2%, 95% CI = 40.8-41.6%, PR = 0.99, 95% CI = 0.99-0.99, P < 0.001), acute eye conditions (2008: 19.8%, 95% CI = 19.4%-20.2% and 2015: 17.4%, 95% CI = 17.1%-17.6%, PR = 0.97, 95% CI = 0.97-0.98, P < 0.001), and blindness (2008: 5.2%, 95% CI = 5.0%-5.4% and 2015: 3.7%, 95% CI = 3.5%-3.9%, PR = 0.93, 95% CI = 0.93-0.94, p < 0.001). decreased over the study period. The prevalence of glaucoma (2008: 13.5%, 95% CI = 13.2%-13.8% and 2015: 13.8%, 95% CI = 13.5%-13.7%; PR = 1.01, 95% CI = 0.99-1.10, P < 0.001) and cataract (2008: 7.4%, 95% CI = 7.2%-7.7% and 2015: 8.5%, 95% CI = 8.3%-8.7%, PR = 1.00, 95% CI = 1.00-1.01, P < 0.001) remained stable or slightly increased. Overall, 46.4% (N = 82,769) of individuals with eye conditions, accessed at least one eye health service within the first year of entering residential care and 70.5% (N = 125,673) used at least one ophthalmic medication. Optometric services (41.7%, N = 74,358) were the most used eye health care services and anti-infective eye drops (37.2%, N = 66,331) were the most commonly dispensed medications.

Conclusions

The prevalence of blindness among older Australian using residential aged care services decreased over the study period. However, the burden of eye diseases remained high between 2008 and 2015, whereas the use of eye health care services was disproportionately low. This study provides evidence of a significant need for eye health care services for older people with an eye disease in residential aged care facilities.

Translational Relevance

Four in ten long term aged care residents in Australia had at least one eye condition over the study period, indicating potential for a high eye health care needs in aged care settings.

[Pharmacogenetics of timolol]

In recent years, β-adrenergic blockers have become the first choice drugs for glaucoma treatment. Timolol holds the main position among them, being a part of most combined antiglaucoma preparations. The use of timolol maleate in clinical practice may be accompanied by severe side effects affecting different organs and systems. The fact that cells with β-adrenergic receptors are widely common within the human body explains pharmacodynamic effects of timolol maleate. Because of these undesirable side effects, timolol maleate often evokes negative reaction from doctors and patients, which to certain extent limits its usage in ophthalmological practice. Obviously, efficacy and safety of timolol administration depends on individual characteristics making personalized approach necessary for every patient. Such particular approach, being the foundation of personalized medicine, increases efficacy and safety of timolol while reducing costs by using targeted doses.

A Single Drop in the Eye - Effects on the Whole Body?

Introduction:

Although the local adverse effects of ophthalmic drugs, including allergic reactions, are well recognized, less is known about the systemic side- effects of eye drops, especially during pregnancy, breast-feeding and early childhood. Ophthalmologists should also be aware of unusual, in some cases even life-threatening, effects of commonly used eye drops.

Conclusion:

This brief review outlines the routes of systemic absorption and the kinetics of active components present in eye drops, and identifies the clinically relevant systemic adverse effects.

Cardiovascular medication and intraocular pressure: results from the Gutenberg Health Study

BACKGROUND

Intraocular pressure (IOP) is well known to be associated with blood pressure and other cardiovascular risk factors. The influence of systemic cardiovascular, in particular antihypertensive, medication on IOP is still controversial. This study analyses the association between the use of cardiovascular medications and IOP in a large European cohort.

METHODS

The Gutenberg Health Study is a population-based, prospective,observational cohort study in mid-western Germany. IOP was measured using a non-contact tonometer. The medication classes examined were peripheral vasodilators, diuretics, β-blockers (overall, selective and non-selective), calcium channel blockers, renin-angiotensin blockers (overall, ACE inhibitors and angiotensin-receptor blockers), nitrates, other antihypertensive medications, aspirin and statins. Subjects with missing IOP values, topical IOP-lowering medication or previous ocular surgery were excluded. In total, 13 527 subjects were enrolled in this study. Association analyses between medication use and IOP were performed using multivariable linear regression (p<0.0038).

RESULTS

Neither selective nor non-selective systemic β-blocker intake was associated with statistically significant lower IOP (-0.12 mm Hg, p=0.054 and -0.70 mm Hg, p=0.037, respectively). IOP was not associated with the use of ACE inhibitors after adjustment for body mass index, systolic blood pressure and central corneal thickness (0.11 mm Hg; p=0.07).

CONCLUSIONS

None of the cardiovascular medications, in particular systemic β-blocking agents, showed an association with IOP in non-glaucoma subjects. The long-term drift phenomenon of topical and systemic β-blocker might explain this result. Our results suggest that systemic β-blockers have a negligible effect on IOP reduction.

Cardiac safety of ophthalmic timolol

INTRODUCTION

It is generally believed that topical administration of eye drops safeguards against harmful systemic effects. However, about 80% of the drug in the ophthalmic products is systemically absorbed and the first-pass metabolism is avoided. Ophthalmic timolol is widely prescribed in the treatment of glaucoma either alone or in the combination eye drop products, many of which have been launched fairly recently. Ophthalmic timolol may cause serious adverse effects such as symptomatic bradycardia, various conduction disorders in the heart, orthostatic hypotension, syncope and falls. Areas covered: In this review we document a number of factors associated with the properties of ophthalmic timolol and specific features of a patient, which may jeopardize patient's cardiac safety even after topical treatment. Expert opinion: Plasma timolol levels are correlated with cardiovascular adverse effects in patients, since timolol is mainly metabolized by cytochrome P450 2D6 (CYP2D6) enzyme in the liver. Patients who are lacking the functional CYP2D6 or who are concomitantly using potent CYP2D6 inhibitor drugs (e.g. paroxetine or fluoxetine) or verapamil or other beta-blockers are at risk of getting serious cardiac adverse effects. Prior to treatment initiation, ECG should be always performed and CYP2D6 genotyping should be considered, if routinely available.

Paroxetine markedly increases plasma concentrations of ophthalmic timolol; CYP2D6 inhibitors may increase the risk of cardiovascular adverse effects of 0.5% timolol eye drops

Although ophthalmic timolol is generally well tolerated, a significant fraction of topically administered timolol can be systemically absorbed. We investigated the effect of the strong CYP2D6 inhibitor paroxetine on the pharmacokinetics of timolol after ophthalmic administration. In a four-phase crossover study, 12 healthy volunteers ingested either paroxetine (20 mg) or placebo daily for 3 days. In phases 1-2, timolol 0.1% gel, and in phases 3-4, timolol 0.5% drops were administered to both eyes. Paroxetine increased the plasma concentrations of timolol with both timolol formulations to a similar degree. The geometric mean ratio (95% confidence interval) of timolol peak concentration was 1.53-fold (1.23-1.91) with 0.1% timolol and 1.49-fold (0.94-2.36) with 0.5% timolol, and that of timolol area under the plasma concentration-time curve (AUC) from time 0 to 12 hours was 1.61-fold (1.26- to 2.06-fold) and 1.78-fold (1.21-2.62), respectively. During paroxetine administration, six subjects on 0.5% timolol drops, but none on 0.1% timolol gel, had plasma timolol concentrations exceeding 0.7 ng/ml, which can cause systemic adverse effects in patients at risk. There was a positive correlation between the AUC from time 0 to 13 hours of paroxetine and the placebo phase AUC from time 0 to infinity of timolol after timolol 0.5% drops (P < 0.05), and a nonsignificant trend after timolol 0.1% gel, consistent with the role of CYP2D6 in the metabolism of both agents. In the orthostatic test, heart rate immediately after upright standing was significantly lower (P < 0.05) during the paroxetine phase than during the placebo phase at 1 and 3 hours after 0.5% timolol dosing. In conclusion, paroxetine and other CYP2D6 inhibitors can have a clinically important interaction with ophthalmic timolol, particularly when patients are using 0.5% timolol formulations.

Characterization of schizophrenia adverse drug interactions through a network approach and drug classification

Antipsychotic drugs are medications commonly for schizophrenia (SCZ) treatment, which include two groups: typical and atypical. SCZ patients have multiple comorbidities, and the coadministration of drugs is quite common. This may result in adverse drug-drug interactions, which are events that occur when the effect of a drug is altered by the coadministration of another drug. Therefore, it is important to provide a comprehensive view of these interactions for further coadministration improvement. Here, we extracted SCZ drugs and their adverse drug interactions from the DrugBank and compiled a SCZ-specific adverse drug interaction network. This network included 28 SCZ drugs, 241 non-SCZs, and 991 interactions. By integrating the Anatomical Therapeutic Chemical (ATC) classification with the network analysis, we characterized those interactions. Our results indicated that SCZ drugs tended to have more adverse drug interactions than other drugs. Furthermore, SCZ typical drugs had significant interactions with drugs of the "alimentary tract and metabolism" category while SCZ atypical drugs had significant interactions with drugs of the categories "nervous system" and "antiinfectives for systemic uses." This study is the first to characterize the adverse drug interactions in the course of SCZ treatment and might provide useful information for the future SCZ treatment.