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Muñoz-Negrete FJ, Topouzis F, Oddone F, Nisslé S, Rokicki D, Januleviciene I, Harasymowycz P, Stalmans I. Preservative-Free Bimatoprost 0.01% Ophthalmic Gel for Glaucoma Therapy: A Phase III Randomized Controlled Trial. J Glaucoma 2024; 33:422-430. [PMID: 38506750 PMCID: PMC11146180 DOI: 10.1097/ijg.0000000000002371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 02/05/2024] [Indexed: 03/21/2024]
Abstract
PRCIS Noninferiority of efficacy was demonstrated for a preservative-free bimatoprost 0.01% compared with BAK-containing bimatoprost 0.01% following a 12-week treatment period in patients with open angle glaucoma or ocular hypertension. Improved tolerability, in particular conjunctival hyperemia, was also observed. PURPOSE To evaluate the intraocular pressure (IOP)-lowering efficacy and safety of a preservative-free bimatoprost 0.01% ophthalmic gel (PFB 0.01% gel) compared with preserved bimatoprost 0.01% (PB 0.01%). DESIGN Phase III, international, multicenter, randomized, 2-parallel group, investigator-masked, 3-month treatment duration. METHODS Patients with glaucoma or ocular hypertension were randomized after a 7-week run-in/washout period to receive once-daily PFB 0.01% gel (n=236) or PB 0.01% (n=249) for 3 months. The primary efficacy measure was changed from baseline in IOP at week 12. Safety measures included adverse events (AEs) and assessment of conjunctival hyperemia. RESULTS The mean changes from baseline in IOP at week 12 in the PFB 0.01% gel and PB 0.01% were -9.72±2.97 and -9.47±3.06 mm Hg, respectively, at 8 am , -9.41±3.03 and -9.19±3.12 mm Hg at 10 am , and -8.99±3.36 and -8.54±3.44 mm Hg at 4 pm . Noninferiority of PFB 0.01% gel to PB 0.01% was demonstrated at week 12 based on predetermined criteria (upper 95% CI margin of 1.5 mmHg at all time points). The most frequently reported AE was conjunctival hyperemia; 13 (5.5%) patients with PFB 0.01% gel and 17 (6.8%) patients with PB 0.01%. The percentage of patients experiencing a worsening from baseline in conjunctival hyperemia score was lower with PFB 0.01% gel compared to PB 0.01% at week 6 (20.1% vs. 29.3%, respectively) and week 12 (18.3% vs. 30.4%, respectively). CONCLUSIONS PFB 0.01% ophthalmic gel has the same efficacy in lowering IOP as PB 0.01% and demonstrated less aggravation of conjunctival hyperemia at weeks 6 and 12.
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Affiliation(s)
- Francisco J. Muñoz-Negrete
- Department of Ophthalmology, Hospital Universitario Ramón y Cajal
- Faculty of Medicine, University of Alcalá, IRYCIS, Madrid, Spain (Facultad de Medicina, Universidad de Alcalá, IRYCIS, Madrid, Spain)
| | - Fotis Topouzis
- Department of Ophthalmology, School of Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Francesco Oddone
- Clinical and Research Institute of Ophthalmology, IRCCS—Fondazione Bietti, Rome, Italy
| | | | | | - Ingrida Januleviciene
- Department of Ophthalmology, Eye Clinic of Medical Academy of Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Paul Harasymowycz
- Department of Ophthalmology, University of Montreal
- Bellevue Ophthalmology Clinics and Montreal Glaucoma Institute, Montreal, Canada
| | - Ingeborg Stalmans
- Department of Ophthalmology, University Hospitals UZ Leuven
- Laboratory of Ophthalmology, Research Group of Ophthalmology, Catholic University KU Leuven, Leuven, Belgium
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Nagstrup AH. The use of benzalkonium chloride in topical glaucoma treatment: An investigation of the efficacy and safety of benzalkonium chloride-preserved intraocular pressure-lowering eye drops and their effect on conjunctival goblet cells. Acta Ophthalmol 2023; 101 Suppl 278:3-21. [PMID: 38037546 DOI: 10.1111/aos.15808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
ENGLISH SUMMARY Glaucoma is a leading cause of the global prevalence of irreversible blindness. The pathogenesis of glaucoma is not entirely known, but the major risk factors include advancing age, genetic predisposition, and increased intraocular pressure (IOP). The only evidence-based treatment is a lowering of IOP through the use of eye drops, laser procedures, or surgical interventions. Although laser treatment is gaining recognition as a first-choice treatment option, the most common approach for managing glaucoma is IOP-lowering eye drops. A major challenge in the treatment is the occurrence of adverse events and poor adherence. In this context, the ocular surface is an area of great concern, as most glaucoma patients have dry eye disease (DED), which is largely caused by eye drops. Preservation with benzalkonium chloride (BAK) is a controversial topic due to its potential role as a significant cause of DED. A systematic review and meta-analyses investigate potential differences in efficacy and safety between BAK-preserved and BAK-free anti-glaucomatous eye drops (I). Many of the included studies report on ocular surface damage caused by the application of BAK-preserved eye drops. However, the meta-analyses addressing hyperemia, number of ocular adverse events, and tear break-up time did not identify any significant differences. The latter is likely due to varying measurement methods, different endpoints, and study durations. It is, therefore, possible that the large variations between the studies conceal differences in the safety profiles. The efficacy meta-analysis finds that there are no differences in the IOP-lowering effect between BAK-preserved and BAK-free eye drops, indicating that BAK is not necessary for the effectiveness of eye drops. To promote more homogeneous choices of endpoints and methods when evaluating BAK-preserved and BAK-free glaucoma treatments, a Delphi consensus statement was performed. In this study, glaucoma experts and ocular surface disease experts reached consensus on the key factors to consider when designing such studies (II). The hope is to have more studies with comparable endpoints that can systematically show the potentially adverse effects of BAK. The preclinical studies in the current Ph.D. research focus on conjunctival goblet cells (GCs). GCs are important for the ocular surface because they release the mucin MUC5AC, which is an essential component of the inner layer of the tear film. BAK preservation may damage the GCs and result in a low GC density, leading to an unstable tear film and DED. The most commonly used IOP-lowering drugs are prostaglandin analogs (PGAs). Thus, the conducted studies investigate the effect of PGAs preserved in different ways on GCs. BAK-preserved latanoprost is cytotoxic to primary cultured human conjunctival GCs and results in a scattered expression of MUC5AC, in contrast to negative controls, where MUC5AC is localized around the cell nucleus (III). Preservative-free (PF) latanoprost is not cytotoxic and does not affect the MUC5AC expression pattern. Furthermore, BAK-preserved travoprost is found to be cytotoxic in a time-dependent manner, while Polyquad®-preserved travoprost does not affect GC survival at any measured time point (IV). Both Polyquad and BAK induce scattered expression of MUC5AC. The cytotoxicity of BAK-preserved PGA eye drops is higher compared to the safer profile of PF and Polyquad-preserved PGA eye drops (V). Additionally, PF latanoprost does not increase the release of the inflammatory markers interleukin (IL)-6 and IL-8, unlike BAK-preserved latanoprost. A review highlights the active and inactive components of IOP-lowering eye drops (VI). Several preclinical and clinical studies have identified adverse effects of BAK. Although other components, such as the active drug and phosphates, can also cause adverse events, the review clearly states that BAK alone is a major source of decreased tolerability. The conclusion of this thesis is that BAK preservation is unnecessary and harmful to the ocular surface. The preclinical studies demonstrate that GCs die when exposed to BAK. Furthermore, they find that BAK induces a pro-inflammatory response. The review included in the thesis concludes that BAK should be phased out of eye drops for chronic use. Overall, the inclusion of BAK poses a risk of developing DED and poor adherence, which can ultimately lead to disease progression and blindness.
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Affiliation(s)
- Anne Hedengran Nagstrup
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
- Department of Ophthalmology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
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Bacharach J, Ahmed IIK, Sharpe ED, Korenfeld MS, Zhang S, Baudouin C. Preservative-Free versus Benzalkonium Chloride-Preserved Latanoprost Ophthalmic Solution in Patients with Primary Open-Angle Glaucoma or Ocular Hypertension: A Phase 3 US Clinical Trial. Clin Ophthalmol 2023; 17:2575-2588. [PMID: 37674591 PMCID: PMC10478989 DOI: 10.2147/opth.s414015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 08/18/2023] [Indexed: 09/08/2023] Open
Abstract
Purpose To evaluate the safety and efficacy of a preservative-free latanoprost 0.005% formulation (T2345) in patients with primary open-angle glaucoma (POAG) or ocular hypertension (OHT) compared to benzalkonium chloride-preserved latanoprost 0.005% (BPL) formulation in the United States (US). Patients and Methods A prospective, randomized, multicenter, observer-masked, parallel-group study enrolled 335 patients diagnosed with POAG or OHT from 31 US sites who had adequately controlled intraocular pressure (IOP; ≤18 mm Hg) with latanoprost monotherapy. After a ≥72-hour washout period, patients were randomized to T2345 (n=165) or BPL (n=170) groups. Study drugs were dosed once-daily from Day 0 to Day 84 in one or both eyes. The study eye was the eye with lower IOP at baseline. The primary efficacy measure was the between-group comparison of the mean IOP values in the study eye at each time point (8 AM, 10 AM, and 4 PM on Days 15, 42, and 84). Safety measurements included ocular and systemic treatment-emergent adverse events (TEAEs). Results Both T2345 and BPL adequately controlled IOP with 95% CIs within 1.5 mm Hg in the study eye at all assessed time points. The percentages of patients with diurnal IOP <18 mm Hg at Day 84 were 73.1% vs 78.7% for the T2345 and BPL groups, respectively. Adverse events were generally mild-to-moderate and primarily ocular. Fewer patients in the T2345 group experienced ocular TEAEs (13.9% vs 22.5%, respectively) and TEAEs with a suspected relationship to the study medication compared with the BPL group (5.5% vs 11.8%, respectively). The most common ocular TEAEs were instillation site pain and conjunctival hyperemia. Conclusion In patients with POAG or OHT, both T2345 and BPL maintained IOP at or below clinically meaningful values for the duration of the study. T2345 showed a favorable safety profile, with numerically lower incidences of ocular TEAEs than BPL.
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Affiliation(s)
| | | | | | | | | | - Christophe Baudouin
- Quinze-Vingts National Ophthalmology Hospital & Vision Institute, Paris Saclay-Versailles-Saint Quentin University, IHU Foresight, Paris, France
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Current progress in preservative-free topical ophthalmic formulations. J Drug Deliv Sci Technol 2022. [DOI: 10.1016/j.jddst.2022.103996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Fineide F, Lagali N, Adil MY, Arita R, Kolko M, Vehof J, Utheim TP. Topical glaucoma medications – Clinical implications for the ocular surface. Ocul Surf 2022; 26:19-49. [DOI: 10.1016/j.jtos.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 07/21/2022] [Accepted: 07/22/2022] [Indexed: 11/25/2022]
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Thein AS, Hedengran A, Azuara-Blanco A, Arita R, Cvenkel B, Gazzard G, Heegaard S, de Paiva CS, Petrovski G, Prokosch-Willing V, Utheim TP, Virgili G, Kolko M. Adverse effects and Safety in Glaucoma Patients - Agreement on Clinical Trial Outcomes for Reports on Eye Drops (ASGARD) - A Delphi Consensus Statement. Am J Ophthalmol 2022; 241:190-197. [PMID: 35594917 DOI: 10.1016/j.ajo.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 05/08/2022] [Accepted: 05/09/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this study is to establish consensus among experts on outcomes and methods to be used in clinical trials to assess adverse effects of anti-glaucomatous eye drops. DESIGN Modified Delphi method. METHODS Clinical experts from Europe, North America, South America, the Middle East, and Asia were invited to participate in two sequential web-based surveys administered from June 27 to August 29, 2021. A total of 91 clinical experts were invited to participate. Of these, 71 (78%) experts from 23 different countries accepted the invitation and answered the first questionnaire. The importance of items was ranked using a 10-point scale (1 as not important, 10 as very important). RESULTS A total of 84 items were rated in round one by 71 participants. Of these, 68 (81%) reached consensus. In round two, 19 items, including three additional items, were rated by 53 (75%) participants. Consensus was reached in 98% of investigated items. Eight outcomes were agreed as important to assess when conducting future trials: ocular surface, dryness, epithelial damage, local adverse effects related to eye drops as reported by patients, periocular surroundings and eyelids, quality of life questionnaires, hyperemia, visual acuity, tear film, and anterior chamber inflammation. CONCLUSION We propose a consensus-based series of outcomes and assessment methods to be used in clinical trials assessing adverse effects of anti-glaucomatous eye drops. This will hopefully improve the comparability of results from future trials and thus facilitate meta-analyses and progress in this field.
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Skov AG, Rives AS, Freiberg J, Virgili G, Azuara‐Blanco A, Kolko M. Comparative efficacy and safety of preserved versus preservative-free beta-blockers in patients with glaucoma or ocular hypertension: a systematic review. Acta Ophthalmol 2022; 100:253-261. [PMID: 34128326 DOI: 10.1111/aos.14926] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/20/2021] [Indexed: 12/28/2022]
Abstract
Preservative-free topical medications have been introduced for glaucoma care to reduce ocular adverse events associated with preservatives. This is a systematic review and meta-analysis of randomized clinical trials (RCTs) comparing the efficacy and safety of beta-blockers, or combination using beta-blockers, with and without preservatives. PubMed, EMBASE and Web of Science were examined. Risk of bias was assessed using the Cochrane Handbook for Systematic Reviews. The primary outcome was change in intraocular pressure (IOP) from baseline to final follow-up. Secondary outcomes included ocular and systemic side effects, and other clinical and quality of life outcomes. Of 242 records identified, seven RCTs (1125 patients) were included. The follow-up period ranged from one to 12 months. Timolol was used in five studies, and two studies used a combination (timolol with bimatoprost or dorzolamide). The difference in mean change (MD) in IOP between the preservative-free and the preserved drugs was statistically significant but not clinically relevant: (MD 0.29 mmHg, 95% confidence interval 0.07-0.51 mmHg, p = 0.010; moderate-certainty evidence). Regarding adverse events: Level of evidence for all ocular surface outcome was low or very low and reported in few studies. No significant difference was observed on ocular surface symptoms. Tear break-up time (TBUT) was better with preservative-free drops (p < 0.001). Schirmer's test was better in the preservative-free group (p < 0.001). Level of evidence for all ocular surface outcomes was low or very low. There was no difference in other secondary outcomes. We found no clinically relevant difference in mean change in IOP between the preserved and the preservative-free treatments. Data on adverse events used different methods and were incompletely reported. Although some measures of ocular surface health favoured preservative-free medications, more evidence is needed. The increasing use of preservative-free drops may be associated with better ocular surface and tolerability, but strong evidence from RCTs would be welcome.
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Affiliation(s)
- Anne Guldhammer Skov
- Department of Ophthalmology Copenhagen University Hospital Rigshospitalet‐Glostrup Glostrup Denmark
| | | | - Josefine Freiberg
- Department of Drug Design and Pharmacology University of Copenhagen Copenhagen Denmark
| | - Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA) University of Firenze and AOU Careggi Florence Italy
- Centre for Public Health Queen’s University Belfast Belfast UK
| | | | - Miriam Kolko
- Department of Ophthalmology Copenhagen University Hospital Rigshospitalet‐Glostrup Glostrup Denmark
- Department of Drug Design and Pharmacology University of Copenhagen Copenhagen Denmark
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Müllertz O, Hedengran A, Mouhammad ZA, Freiberg J, Nagymihály R, Jacobsen J, Larsen SW, Bair J, Utheim TP, Dartt DA, Heegaard S, Petrovski G, Kolko M. Impact of benzalkonium chloride-preserved and preservative-free latanoprost eye drops on cultured human conjunctival goblet cells upon acute exposure and differences in physicochemical properties of the eye drops. BMJ Open Ophthalmol 2021; 6:e000892. [PMID: 34993350 PMCID: PMC8689192 DOI: 10.1136/bmjophth-2021-000892] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/30/2021] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To investigate the short-term impact on human conjunctival goblet cell (GC) survival and mucin release of acute exposure to benzalkonium chloride (BAK) preserved and preservative-free (PF) 0.005% (w/v) latanoprost (LT) eye drops, and to compare the eye drops' physicochemical properties. METHODS AND ANALYSIS Primary GC cultures were established from human conjunctival donor tissue. The impact of eye drops on GC survival was assessed using a lactate dehydrogenase assay. Mucin release was evaluated through mucin-specific immunostaining. pH value, osmolality, drop mass and surface tension for all LT eye drops were measured. RESULTS After application with PF-LT for 30 min (min), the GC survival was maintained compared with control (p=0.9941), while all BAK-LT eye drops reduced survival with approximately 30% (p<0.02). Following application with PF-LT for 30 min, mucin was found around the GC nucleus, as seen in the vehicle control, indicating no secretion. In contrast, BAK-LT caused diffuse staining of mucin, similar to the secretagogue histamine, indicating stimulation of secretion. The pH value of the BAK-LT and PF-LT eye drops were 6.0-6.9 and 6.8, respectively. The osmolality was 258-288 mOsm/kg for the BAK-LT eye drops and 276 for PF-LT eye drops. The mean drop mass was 26-31 mg for the BAK-LT eye drops and 30 mg for PF-LT. The surface tension was lower for all BAK-LT eye drops (31.1-32.1 mN/m) compared with PF-LT (42 mN/m). CONCLUSION PF-LT compared with various branded and generic LT preparations containing BAK are less cytotoxic when applied to cultured GCs.
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Affiliation(s)
- Olivia Müllertz
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Anne Hedengran
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
- Department of Ophthalmology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Zaynab Ahmad Mouhammad
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Josefine Freiberg
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Richárd Nagymihály
- Center for Eye Research, Department of Ophthalmology, Oslo University Hospital and Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jette Jacobsen
- Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
| | - Susan Weng Larsen
- Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
| | - Jeffrey Bair
- Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Schepens Eye Research Institute, Boston, Massachusetts, USA
| | - Tor P Utheim
- Department of Medical Biochemistry, Oslo Universitetssykehus, Oslo, Norway
- Department of Ophthalmology, Sørlandet Hospital Arendal, Arendal, Norway
| | - Darlene A Dartt
- Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Schepens Eye Research Institute, Boston, Massachusetts, USA
| | - Steffen Heegaard
- Department of Ophthalmology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Pathology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Goran Petrovski
- Center for Eye Research, Department of Ophthalmology, Oslo University Hospital and Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Miriam Kolko
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
- Department of Ophthalmology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Comparison of the Safety and Efficacy between Preserved and Preservative-Free Latanoprost and Preservative-Free Tafluprost. Pharmaceuticals (Basel) 2021; 14:ph14060501. [PMID: 34073977 PMCID: PMC8225154 DOI: 10.3390/ph14060501] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 12/19/2022] Open
Abstract
In this study, we investigated the effect of preservative-free (PF) 0.0015% tafluprost (TA), to the preservative containing (PC) and the PF 0.005% latanoprost (LA) in Korean subjects. This study was conducted as a multi-center, randomized, investigator-blind, active controlled, parallel-group, clinical trial in adult patients (≥19 years) with open-angle glaucoma (OAG) and ocular hypertension (OHT). After a washout period, patients with an IOP between 15 and 35 mmHg were enrolled and evaluated the efficacy, safety, and compliance at 4, 8 and 12 weeks after the first administration. A total of 137 OAG and OHT patients were randomized. Statistically significant reductions in IOP were observed in all groups. Twelve weeks after each eye drop instillation, the mean IOP reduction was −4.59 ± 2.70 mmHg (−24.57 ± 13.49%) in the PC-LA group, −4.52 ± 2.17 mmHg (−24.41 ± 11.38%) in the PF-LA, and −3.14 ± 2.83 mmHg (−17.22 ± 14.57%) in the PF-TA group. The PF-LA showed significantly better responsiveness than did PF-TA. PF-LA was better tolerated than was PC-LA. There were no adverse events that led to cessation of eye drop use in any of the groups. In conclusion, IOP decreased similarly across the groups. PF-LA may provide a good choice for OAG patients with ocular surface diseases.
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Figus M, Agnifili L, Lanzini M, Brescia L, Sartini F, Mastropasqua L, Posarelli C. Topical preservative-free ophthalmic treatments: an unmet clinical need. Expert Opin Drug Deliv 2020; 18:655-672. [PMID: 33280452 DOI: 10.1080/17425247.2021.1860014] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: The main role of preservatives in eyedrops is to ensure sterility and microbiological integrity of the drug, and to facilitate the penetration of active compounds into the eye. However, several studies documented significant toxic effects induced by preservatives, especially on the ocular surface. Consequently, most of the ophthalmic medications became progressively available in preservative-free (PF) formulations.Areas covered: We analyzed pre-clinical and clinical studies on PF eyedrops with particular attention to common chronic diseases such as dry eye and glaucoma. We discussed about the pros and cons of using PF eyedrops, in terms of efficacy, safety, and social-economic aspects.Expert opinion: There are still unresolved issues that make hard for PF medications to definitively conquer the drug market. Despite robust pre-clinical evidences of less toxicity, the low number of randomized clinical trials does not permit to state that PF eyedrops have, in clinical practice, a similar efficacy or a higher safety compared to preserved forms. These aspects limit their use to chronic diseases requiring long-term therapies with multiple daily instillations, especially in the presence of concomitant ophthalmic diseases that expose to a risk of ocular surface worsening.
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Affiliation(s)
- Michele Figus
- Ophthalmology, Department of Surgical, Medical, Molecular Pathology and of Critical Area, University of Pisa, Pisa, Italy
| | - Luca Agnifili
- Ophthalmology Clinic, Department of Medicine and Aging Science, University G. D'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Manuela Lanzini
- Ophthalmology Clinic, Department of Medicine and Aging Science, University G. D'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Lorenza Brescia
- Ophthalmology Clinic, Department of Medicine and Aging Science, University G. D'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Francesco Sartini
- Ophthalmology, Department of Surgical, Medical, Molecular Pathology and of Critical Area, University of Pisa, Pisa, Italy
| | - Leonardo Mastropasqua
- Ophthalmology Clinic, Department of Medicine and Aging Science, University G. D'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Chiara Posarelli
- Ophthalmology, Department of Surgical, Medical, Molecular Pathology and of Critical Area, University of Pisa, Pisa, Italy
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Lee SM, Jin SW. Efficacy of Preservative-free Latanoprost in Normal-tension Glaucoma with Mild to Moderate Dry Eye. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2020. [DOI: 10.3341/jkos.2020.61.6.639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Inoue D, Mohamed YH, Uematsu M, Kitaoka T. Corneal damage and its recovery after instillation of preservative-free versus preserved latanoprost eye drops. Cutan Ocul Toxicol 2020; 39:158-164. [PMID: 32295438 DOI: 10.1080/15569527.2020.1752228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Purpose: Latanoprost ophthalmic solution is highly effective as a therapeutic agent for glaucoma and is applied worldwide. However, harmful effects on the corneal surface have been reported regarding the commercially available latanoprost ophthalmic solution. Corneal surface toxicity may be caused by the added preservative of the ophthalmic solution. In order to ascertain whether latanoprost itself can damage the cornea or if this is solely due to the added preservatives, this study attempted to determine the corneal changes that occur at different time periods following usage of preservative-free versus preserved latanoprost eye drops.Materials and methods: Preservative-free latanoprost eye drops (Monoprost®) or preserved latanoprost eye drops (Xalatan®) containing 0.02% benzalkonium chloride (BAC) were instilled in the corneas of rabbits. For each of the two different eye drop solutions, the rabbits used in this experiment were divided into three exposure groups: 1 minute, 24 hour, and 1 week groups. Corneal transepithelial electrical resistance (TER) and scanning electron microscopy (SEM) were examined immediately (1 minute) after instillation, at 24 hours after instillation, and at 24 hours after 1 week of daily instillations of latanoprost. Hank's balanced salt solution was used in the control group.Results: The mean corneal TER of the control group was 933.8 ± 279.0 Ω cm2. In preservative-free latanoprost instilled corneas, there was no significant decrease in the TER or morphological changes at any of the time points, with the relative TER values of 117 ± 38%, 100 ± 34%, and 93 ± 21% for 1 minute, 1 day, and 1 week time points, respectively. In preserved latanoprost instilled corneas, SEM showed that only the immediate group exhibited superficial cell damage and a significant decrease in the corneal TER compared to the controls and other time points and to the immediate preservative-free latanoprost corneas. In the preserved latanoprost groups, the relative TER values were 18 ± 5%, 110 ± 28%, and 92 ± 10%, for the three respective observation time points.Conclusions: Preservative-free latanoprost can be safely instilled to the corneal epithelium. Latanoprost with 0.02% BAC has an immediate deleterious impact on the corneal epithelium; however, it disappears within 24 hours after instillation.
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Affiliation(s)
- Daisuke Inoue
- Department of Ophthalmology and Visual Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Yasser Helmy Mohamed
- Department of Ophthalmology and Visual Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan.,Department of Ophthalmology, EL-Minia University Hospital, EL-Minia, Egypt
| | - Masafumi Uematsu
- Department of Ophthalmology and Visual Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Takashi Kitaoka
- Department of Ophthalmology and Visual Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
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Aptel F, Pfeiffer N, Schmickler S, Clarke J, Lavín-Dapena C, Moreno-Montañés J, Żarnowski T, Csutak A, Jugaste T, Volksone L, Astakhov YS, Coupier L, Nordmann JP, Stalmans I. Noninferiority of Preservative-free Versus BAK-preserved Latanoprost-timolol Fixed Combination Eye Drops in Patients With Open-angle Glaucoma or Ocular Hypertension. J Glaucoma 2019; 28:498-506. [PMID: 31166287 DOI: 10.1097/ijg.0000000000001248] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PRéCIS:: Noninferiority of efficacy was demonstrated for a preservative-free latanoprost-timolol fixed combination compared with a BAK-containing formulation at 84 days after treatment in patients with open-angle glaucoma or ocular hypertension. PURPOSE The purpose of this study was to compare the effect on intraocular pressure and safety of preservative-free latanoprost-timolol fixed combination (T2347) to benzalkonium chloride-preserved latanoprost-timolol fixed combination in patients with open-angle glaucoma or ocular hypertension. METHODS Phase III, randomized, parallel-group, investigator-masked study in 10 countries. A total of 242 patients aged 18 years or older with open-angle glaucoma or ocular hypertension in both eyes controlled with a preserved latanoprost-timolol fixed combination (15.7±2.4 mm Hg overall before inclusion) were randomized at day 0 with no washout period to receive the preservative-free alternative T2347 (N=127) or remain on the preserved comparator (N=115) for 84 days. Intraocular pressure changes from day 0 were measured at 9:00 am (±1 hour) on day 42 and day 84, and noninferiority of T2347 to the preserved comparator was analyzed statistically at day 84. Safety parameters were also reported. RESULTS The mean change in intraocular pressure from baseline to day 84 was -0.49±1.80 mm Hg for preservative-free T2347 and -0.49±2.25 mm Hg for the preserved comparator. These results met the noninferiority limits. Similar results were observed at day 42. There was no difference between groups in the incidence of adverse events or ocular signs. The total ocular symptoms score was better for T2347 than BPLT upon instillation at day 84 (45.9%/44.3%/9.8% of patients with improvement/no change/worsening vs. 33.6%/47.3%/19.1%; P=0.021), reflecting improvements in individual symptoms such as irritation/burning/stinging (P<0.001), and itching (P<0.01) on day 84. CONCLUSIONS Preservative-free latanoprost-timolol fixed combination T2347 showed noninferior efficacy compared with the preserved comparator and was well tolerated.
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Affiliation(s)
- Florent Aptel
- CHU de Grenoble/University Hospital of Grenoble, Université Grenoble Alpes, Grenoble
| | - Norbert Pfeiffer
- Department of Ophthalmology, Mainz University Medical Center, Mainz
| | | | - Jonathan Clarke
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
| | | | | | - Tomasz Żarnowski
- Department of Diagnostics and Microsurgery of Glaucoma, Medical University, Lublin, Poland
| | - Adrienne Csutak
- Department of Ophthalmology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | | | - Lāsma Volksone
- Dr Volksone's Practice in Ophthalmology, Lavolks Ltd, Ri[Combining Macron]ga, Latvia
| | - Yury S Astakhov
- Department of Ophthalmology, Academician I.P. Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - Laurent Coupier
- Centre Hospitalier du Pays d'Aix, Service Ophtalmologie, Aix-en-Provence
| | | | - Ingeborg Stalmans
- Department of Ophthalmology, University Hospitals UZ Leuven, Leuven, Belgium
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Extracellular MMP-9-Based Assessment of Ocular Surface Inflammation in Patients with Primary Open-Angle Glaucoma. J Ophthalmol 2019; 2019:1240537. [PMID: 31073413 PMCID: PMC6470422 DOI: 10.1155/2019/1240537] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 03/11/2019] [Indexed: 11/17/2022] Open
Abstract
Purpose Objective assessment of dry eye disease (DED) severity and ocular inflammation using the InflammaDry® test for extracellular matrix metalloproteinase-9 (MMP-9) and the impact of antiglaucoma eye drops in people with primary open-angle glaucoma (POAG). Methods Overall, 90 adults (180 eyes) were included: 60 had been diagnosed with POAG and were treated with prostaglandin analogue monotherapy and 30 were suspected of having POAG but did not receive any treatment (control group). Of those treated with prostaglandin eye drops, 30 received a preservative-free formulation (tafluprost) and 30 were treated with a formulation containing the preservative benzalkonium chloride (BAK) (latanoprost). Measurement of extracellular MMP-9 levels (InflammaDry test) provided a marker for ocular surface inflammation. Further assessments of disease severity and inflammation comprised Goldmann applanation tonometry for intraocular pressure (IOP), Schirmer's test with anesthesia, ocular surface staining with unpreserved fluorescein (Oxford scale index), tear breakup time (TBUT), McMonnies questionnaire, and the Ocular Surface Disease index (OSDI). Results Clinically significant MMP-9 levels (>40 ng/mL) were detected in tear film from 46.7% of subjects treated with BAK-containing medication. In contrast, only 16.7% of subjects treated with preservative-free medication or untreated individuals demonstrated similar MMP-9 levels. This difference was statistically significant (p < 0.05). MMP-9 results correlated with other indicators of inflammation and disease severity. BAK-containing medication was associated with rapid TBUT (<5 seconds) in 50% of cases, while only 10% of untreated subjects and individuals using preservative-free medication demonstrated comparable TBUT results. Conclusion Measurement of ocular surface MMP-9 level provides a useful marker for inflammation and DED in POAG. Use of a preservative-free topical prostaglandin formulation results in lower levels of ocular inflammation, compared with BAK-containing medication.
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Martinez-de-la-Casa JM, Donde S, Wierzbowska J. Latanoprost, a balanced prostaglandin. EXPERT REVIEW OF OPHTHALMOLOGY 2019. [DOI: 10.1080/17469899.2019.1567331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
| | - Shaantanu Donde
- Global Medical Affairs, Pfizer Essential Health, Tadworth, UK
| | - Joanna Wierzbowska
- Department of Ophthalmology, Military Institute of Medicine, Warsaw, Poland
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Economou MA, Laukeland HK, Grabska-Liberek I, Rouland JF. Better tolerance of preservative-free latanoprost compared to preserved glaucoma eye drops: the 12-month real-life FREE study. Clin Ophthalmol 2018; 12:2399-2407. [PMID: 30538423 PMCID: PMC6263246 DOI: 10.2147/opth.s176605] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Lack of efficacy due to bad compliance caused by intolerance issues is the main reason for a change to a better tolerated ocular treatment, such as using preservative-free (PF) eye drops. Aim To assess the efficacy and local tolerance after 12 months and patient satisfaction regarding local treatment tolerance and handling at inclusion and after 6 months of PF latanoprost compared to preserved glaucoma eye drops. Methods This was an international, prospective, and observational real-life study. Up to three visits, one at inclusion and two follow-up visits (one after 6 and one after 12 months) were planned. Efficacy, local tolerance, and patient satisfaction were the main evaluation criteria. Results Data from 721 patients were available for the statistical analysis. Overall, 64.8% (467/721) of patients switched treatment before inclusion: 62.2% in the preserved and 68.9% in the PF latanoprost group. IOP values were similar between PF latanoprost and preserved eye drops and remained stable at all visits. Ocular signs and symptoms improved after switching to PF latanoprost; the prevalence of conjunctival hyperemia was significantly lower (P=0.0015) at both follow-up visits. At follow-up visit 1, 49.5% of the patients who switched to PF latanoprost decreased or stopped the use of artificial tears. Satisfaction regarding tolerance in patients using PF latanoprost improved significantly after the switch from preserved eye drops to PF latanoprost (88.9% and 42.5%, respectively, P<0.0001). Conclusion This first real-life study showed that PF latanoprost was as efficacious but better tolerated than preserved eye drops over a sustained period of 12 months, while providing a significantly higher patient satisfaction and potentially allowing improvement in the patient’s daily life.
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Affiliation(s)
- Mario A Economou
- Anterior Segment Department, St Erik's Eye Hospital, Karolinska Institute, Stockholm, Sweden,
| | - Helene Kolstad Laukeland
- Department of Ophthalmology, University Hospital, Trondheim, Norway.,Department of Laboratory Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Iwona Grabska-Liberek
- Department of Ophthalmology, Ophthalmology Clinic Postgraduate Centre of Medical Education, Warszawa, Poland
| | - Jean-François Rouland
- Department of Ophtalmology, Claude Huriez Hospital, University Hospital, Lille, France
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Martinez-de-la-Casa JM, Perez-Bartolome F, Urcelay E, Santiago JL, Moreno-Montañes J, Arriola-Villalobos P, Benitez-del-Castillo JM, Garcia-Feijoo J. Tear cytokine profile of glaucoma patients treated with preservative-free or preserved latanoprost. Ocul Surf 2017; 15:723-729. [DOI: 10.1016/j.jtos.2017.03.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 03/21/2017] [Accepted: 03/21/2017] [Indexed: 12/26/2022]
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Abstract
This literature review is focused on the prostaglandin topical analogues and describes peculiarities of their structure, pharmacokinetics and pharmacodynamics, results of clinical trials and meta-analyzes, as well as modern trends in the topical IOP-lowering glaucoma therapy evolution.
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