The effectiveness and safety of brimonidine as mono-, combination, or replacement therapy for patients with primary open-angle glaucoma or ocular hypertension: a post hoc analysis of an open-label community trial. Glaucoma Trial Study Group

Brimonidine tartrate ophthalmic solution 0.025% for redness relief: an overview of safety and efficacy

INTRODUCTION

Ocular redness, or conjunctival hyperemia, is a common ophthalmic sign associated with reduced quality of life. For redness without apparent underlying pathology, topical ophthalmic decongestants have been widely used.

AREAS COVERED

Brimonidine tartrate was approved in 2017 as a topical vasoconstrictor at a 0.025% concentration for relief of ocular redness. Since then, investigators have reported on efficacy and safety findings from studies evaluating low-dose brimonidine for reducing ocular redness.

EXPERT OPINION

Brimonidine is highly selective for α₂-adrenergic receptors. Clinical trials have so far shown that the drug in low doses significantly reduces ocular redness in comparison to vehicle for up to 8 hours. Brimonidine-treated eyes did not present side effects of other vasoconstrictors, such as hypotension, cardiac arrhythmia or drowsiness. Ocular adverse events such as allergic reactions and redness rebound were also minimal. In this review, we examine in detail published literature on the mechanism of brimonidine tartrate and its efficacy and safety in relieving conjunctival hyperemia.

Over-the-Counter Ocular Decongestants in the United States - Mechanisms of Action and Clinical Utility for Management of Ocular Redness

To manage ocular redness effectively, health-care practitioners require an understanding of the pathophysiology, clinical features and differential diagnosis of ocular redness, as well as comprehensive knowledge of medical therapies available and their pharmacologic properties. This review aims to provide a clinically relevant summary of the current literature on the mechanism of action, efficacy, and safety of current over-the-counter (OTC) decongestants available for reduction of ocular redness due to minor irritations. Currently marketed OTC products indicated for such use in the United States include topical solutions of tetrahydrozoline 0.05%, naphazoline 0.012% to 0.03%, and brimonidine 0.025%. All 3 agents are adrenergic receptor agonists but vary in their receptor-binding profiles: tetrahydrozoline is a selective α1 receptor agonist; naphazoline is a mixed α1/α2 receptor agonist; and brimonidine is a selective α2 receptor agonist. These OTC decongestants produce vasoconstriction of conjunctival blood vessels, which results in a rapid reduction in ocular redness. In general, ocular adverse events reported in published studies of these OTC decongestants were minimal, mild, and transient, with no significant adverse systemic effects. However, ocular decongestants with α1-adrenergic receptor agonist activity can be associated with loss of effectiveness with continued use (ie, tachyphylaxis) and rebound redness upon treatment discontinuation. In clinical trials of the selective α2-adrenergic receptor agonist brimonidine 0.025%, tachyphylaxis was not observed, and rebound redness was rarely reported.

A review of neuropsychiatric adverse events from topical ophthalmic brimonidine

Brimonidine is a first-line topical medication for increased intraocular pressure and glaucoma which may be used alone or in conjunction with other topical therapies. Its structural and pharmacological comparabilities to clonidine give way to the hypothesis that it may cause neuropsychiatric side effects. The majority of case reports citing brimonidine toxicity, either for topical or peripheral exposure, include pediatric age groups but especially infants. Among the latter, a dose-response phenomenon is evident. Dose-response correlates have also been shown among adults. Case series and prospective double-blind treatment studies also give evidence for the occurrence of several central nervous system adverse reactions. Topical ophthalmic brimonidine use should be followed for the occurrence of neuropsychiatric disturbances generally, and enhanced vigilance should be maintained for at-risk populations.

The chemotactic properties of various topical brimonidine tartrate ophthalmic preparations

Background

The study aimed to evaluate and compare the leukocyte chemotactic activities of various brimonidine tartrate (BT) eye drop formulations.

Methods

A 96-well dot-blot platet using a Boyden-style well was used to study the chemotactic effects of BT ophthalmic preparations. A modification was made to create blind wells where the tested agents were placed. Leukocytes were isolated from the peripheral blood of healthy volunteers. As positive controls, we used diluted drugs, benzalkonium chloride solution (BAK), zymosan-activated serum, and formyl-methionine-leucine-phenylalanine peptides. The negative control in our study was a phosphate-buffered saline solution. For each experimental condition, we measured leukocyte migration through a Millipore membrane. The differences in the mean migration distance between groups were compared using the analysis of variance (ANOVA).

Results

The measured migration distances (in μm ± SD) were 62.14 ± 3.71 for BT 0.2% with BAK (Alcon Laboratories Inc.); 63.61 ± 3.81 for BT 0.2% with BAK (Allergan Inc); 40.36 ± 3.17 for BT 0.15% without BAK; and 41.02 ± 2.17 for BAK alone. The negative controls showed no chemotactic activity, while the positive controls showed the highest neutrophil migration of all experimental conditions. The differences between BT 0.15% without BAK and the other commercial formulations were statistically significant.

Conclusion

Commercial ophthalmic preparations of BT 0.2% with BAK 0.005% had higher chemotactic properties than the alternative of a lower concentration of BT and without the preservative BAK. Therefore, the latter should be considered for patients with glaucoma or ocular hypertension in order to minimize iatrogenic ocular inflammation.

New technique to reduce systemic side effects of timolol eye drops: The tissue press method-Cross-over clinical trial

IMPORTANCE

Nasolacrimal occlusion (NLO) is effective in reducing systemic absorption of eye drop medication but it is difficult and often performed poorly. We propose an alternative easier and equally effective technique.

BACKGROUND

To test the effectiveness of systemic absorption, we evaluated plasma concentration and ocular effects after topically administered timolol and compared to NLO.

DESIGN

Cross-over trial carried out in Capital Eye Specialist, Wellington.

PARTICIPANTS

A total of 21 subjects over 18 years without contraindications for topical beta-blocker medication and not using systemic beta-blockers.

METHODS

During three clinic visits separated by at least one week, alternative approaches to reduce systemic eye drop absorption were tested. These were: (a) nasolacrimal (punctal) occlusion for 5 min, (b) tissue press method or (c) no intervention. Timolol plasma levels were measured 1 h after drop application. At each visit, baseline measurement of blood pressure, heart rate and intraocular pressure (IOP) were performed, and repeated 1 h after timolol 0.5% eye drop application.

MAIN OUTCOME MEASURES

Comparison of timolol plasma concentration after each intervention. Secondary outcome measurements included effects on blood pressure, heart rate and IOP.

RESULTS

Plasma timolol concentrations after tissue press method and NLO were significantly lower than those without intervention. Comparing tissue press method to NLO, there were no significant differences in plasma levels of timolol, blood pressure, heart rate or IOP.

CONCLUSION AND RELEVANCE

The tissue press method is equally effective as NLO in reducing systemic absorption of timolol. It is also easier and faster to administer.

Low-dose brimonidine for relief of ocular redness: integrated analysis of four clinical trials

BACKGROUND

The aim of this study was to provide an integrated analysis of safety and efficacy data for brimonidine tartrate ophthalmic solution 0.025 per cent (low-dose; Bausch & Lomb Incorporated), a topical vasoconstrictor for relief of ocular redness.

METHODS

Integrated efficacy data from two randomised, double-masked, vehicle-controlled studies in subjects with ocular redness as well as safety data from the two efficacy studies, a vehicle-controlled safety study, and a pharmacokinetic study were analysed. Efficacy outcomes analysed included investigator-assessed ocular redness (scale, 0-4) before treatment instillation and at five to 240 minutes post-instillation on Day 1, at five minutes post-instillation on Days 15 and 29, and one week after treatment discontinuation (Day 36), and redness self-assessed by subjects recorded daily in diaries. Safety assessments included adverse events, ophthalmic examinations, and rebound redness upon treatment discontinuation. Drop comfort (scale, 0-10) was a tolerability measure.

RESULTS

The efficacy population included 117 subjects (brimonidine, n = 78; vehicle, n = 39). The safety population included 635 subjects (brimonidine, n = 426; vehicle, n = 209). Investigator-assessed ocular redness was significantly lower with brimonidine versus vehicle at all post-instillation time points on Day 1 (mean change from pre-instillation of -1.4 units for brimonidine and -0.2 units for vehicle; p < 0.0001). Subject-assessed ocular redness was also significantly lower with brimonidine versus vehicle (mean treatment difference in average daily ratings of -0.9; p < 0.0001). There was no evidence of tachyphylaxis through Day 29 and rebound redness was rare. Incidence of ocular adverse events was low, the most common being reduced visual acuity (brimonidine, 4.0 per cent; vehicle, 4.3 per cent) and conjunctival hyperaemia (2.6 and 2.9 per cent, respectively). Both brimonidine and vehicle were rated as very comfortable (mean post-instillation scores, 0.4-0.5).

CONCLUSION

In this integrated analysis, low-dose brimonidine significantly reduced ocular redness with no tachyphylaxis, and minimal rebound redness, and was generally safe and well tolerated.

Brimonidine Ophthalmic Solution 0.025% for Reduction of Ocular Redness: A Randomized Clinical Trial

SIGNIFICANCE

The α2-adrenergic receptor agonist brimonidine has been reported to induce conjunctival blanching in cataract, strabismus, laser refractive, and filtration procedures. Clinicians are often faced with red eyes with no apparent underlying pathology. Low-dose brimonidine reduced ocular redness in such subjects with efficacy maintained over 1 month and negligible rebound redness.

PURPOSE

The aim of this study was to evaluate the safety and efficacy of brimonidine tartrate ophthalmic solution 0.025% for the treatment of ocular redness.

METHODS

In this single-center, double-masked, phase 3 clinical trial, adult subjects with baseline redness of more than 1 unit in both eyes (0- to 4-unit scale) were randomized 2:1 to brimonidine 0.025% or vehicle. A single dose was administered in-office (day 1); thereafter subjects instilled treatment four times a day for 4 weeks, with clinic visits on days 15, 29, and 36 (7 days post-treatment). Efficacy end points included investigator-evaluated redness 5 to 240 minutes post-instillation on day 1 (primary); investigator-evaluated change from baseline 1, 360, and 480 minutes post-instillation on day 1, and 1 and 5 minutes post-instillation on days 15 and 29; total clearance of redness, and subject-assessed redness. Safety/tolerability measures included adverse events, rebound redness, and drop comfort.

RESULTS

Sixty subjects were randomized (n = 40 brimonidine, n = 20 vehicle). Investigator-assessed redness was lower with brimonidine versus vehicle over the 5- to 240-minute post-instillation period (mean [SE], 0.62 [0.076] vs. 1.49 [0.108]; P < .0001) and at each time point within that period (P < .0001). At 1, 360, and 480 minutes post-instillation, respectively, the mean differences (95% confidence interval) between treatments were -0.73 (-1.05 to -0.41), -0.57 (-0.84 to -0.29), and -0.39 (-0.67 to -0.10), respectively. No tachyphylaxis was evident with brimonidine on days 15 and 29, and minimal rebound redness was observed following discontinuation. Adverse events were infrequent, and brimonidine was rated as very comfortable.

CONCLUSIONS

Brimonidine 0.025% appeared safe and effective for reduction of ocular redness, with an 8-hour duration of action, no evidence of tachyphylaxis, and negligible rebound redness.

Evaluation of Efficacy and Safety of Brimonidine Tartrate Ophthalmic Solution, 0.025% for Treatment of Ocular Redness

Purpose/Aims: This study assessed the efficacy and safety of brimonidine tartrate ophthalmic solution, 0.025% for treating ocular redness in adult subjects.

MATERIALS AND METHODS

This was a single-center, double-masked, randomized, vehicle-controlled, parallel-group study in subjects ≥40 years, with ocular redness. Subjects were randomized 2:1 to brimonidine or vehicle, instilled QID for four weeks. Subjects completed four visits, the last occurring one week after treatment discontinuation. The investigator assessed ocular redness on a scale of 0-4 pre-instillation and 5-240 minutes post-instillation on Day 0, pre-instillation and 5 minutes post-instillation on Days 14 and 28, and on Day35; subjects assessed redness in diaries throughout the 28-day treatment period and following treatment discontinuation. Safety assessments included adverse events (AEs), rebound redness on treatment discontinuation, comprehensive ophthalmic exams, and vital signs. Drop comfort was assessed upon instillation, and 30 seconds and 1 minute post-instillation at Day 0.

RESULTS

Fifty-seven subjects (brimonidine, n = 38; vehicle, n = 19) were randomized. Investigator-assessed ocular redness was significantly reduced with brimonidine across the entire post-instillation time period (overall treatment difference: -1.37; P < 0.0001) and at all individual time points (P < 0.0001). Subject-assessed ocular redness was also significantly lower with brimonidine (P ≤ 0.0005). No tachyphylaxis was evident. There were few ocular AEs, all mild to moderate in severity, and no redness rebound was observed upon brimonidine discontinuation. There were no effects on any safety measures, and both brimonidine and its vehicle were reported to be very comfortable.

CONCLUSIONS

Brimonidine 0.025% appeared safe, well tolerated, and reduced ocular redness for at least 4 hours. No tachyphylaxis or rebound redness upon treatment discontinuation was observed.

Daytime and nighttime effects of brimonidine on IOP and aqueous humor dynamics in participants with ocular hypertension

PURPOSE

The effects of brimonidine on daytime and nighttime intraocular pressure (IOP) and aqueous humor dynamics were evaluated in volunteers with ocular hypertension (OHT).

PATIENTS AND METHODS

Thirty participants with OHT (58.6±1.7 years old, mean±SEM) were enrolled into this randomized, double-masked, cross-over study. For 6 weeks, participants self-administered 0.2% brimonidine or placebo 3 times daily. During daytime and nighttime visits, measurements included aqueous flow (Fa) by fluorophotometry, outflow facility (C) by tonography, episcleral venous pressure (Pev) by venomanometry, and seated and supine IOP by pneumatonometry. Uveoscleral outflow (U) was calculated mathematically.

RESULTS

When treated with placebo, nighttime supine Pev (11.2±0.25 mm Hg) was higher (P<0.05) compared with daytime seated Pev (10.2±0.25 mm Hg), and Fa and U were significantly reduced at night. Brimonidine significantly lowered seated IOP at 9:00 AM and 11:00 AM, 9:00 PM and 11:00 PM and supine IOP at 9:00 AM and 11:00 AM. Brimonidine increased U at 9 AM and 11 AM (P<0.01) and had no effect on daytime and nighttime Fa, C, or Pev.

CONCLUSIONS

In subjects with OHT, brimonidine treatment for 6 weeks significantly reduces seated IOP during the day by increasing uveoscleral outflow. The lack of IOP effect at night can be explained by failure to overcome a normal nighttime reduction of uveoscleral outflow.

Brimonidine in the treatment of glaucoma and ocular hypertension

Treatment in glaucoma aims to lower intraocular pressure (IOP) to reduce the risk of progression and vision loss. The alpha2-adrenergic receptor agonist brimonidine effectively lowers IOP and is useful as monotherapy, adjunctive therapy, and replacement therapy in open-angle glaucoma and ocular hypertension. A fixed combination of brimonidine and timolol, available in some countries, reduces IOP as effectively as concomitant therapy with brimonidine and timolol and offers the convenience of 2 drugs in a single eyedrop. Brimonidine is safe and well tolerated. Its most common side-effects are conjunctival hyperemia, allergic conjunctivitis, and ocular pruritus. The newest formulation of brimonidine, brimonidine-Purite 0.1%, has a higher pH to improve the ocular bioavailability of brimonidine. This formulation contains the lowest effective concentration of brimonidine and is preserved with Purite(R) to enhance ocular tolerability. Brimonidine-Purite 0.1% is as effective in reducing IOP as the original brimonidine 0.2% solution preserved with benzalkonium chloride. Recent results from preclinical and clinical studies suggest that brimonidine may protect retinal ganglion cells and their projections from damage and death independently of its effects on IOP. The potential for neuroprotection with brimonidine is an added benefit of its use in glaucoma and ocular hypertension.

The management of glaucoma and intraocular hypertension: current approaches and recent advances

In the last decade, numerous novel ocular hypotensive agents have been introduced for the control of intraocular pressure (IOP). Clinicians now have more options than ever in the selection of medical therapy for the treatment of glaucoma and ocular hypertension. When selecting an ocular hypotensive medication for their patients, clinicians should consider not only the IOP-lowering efficacy of an agent, but also the ability of the drug to allow patients to achieve target levels of IOP that are low enough to stop the progression of glaucomatous damage. Other considerations should include how well the drug controls diurnal IOP, the likelihood of serious adverse events, the versatility of the medication for use as an adjunctive agent, as well as other potential attributes (ie, neuroprotection).

Update on the role of alpha-agonists in glaucoma management

Glaucoma is the second most common cause of world blindness (following cataract) with estimated cases reaching 79.6 million by 2020. Although the etiology of glaucoma is multi-factorial, intraocular pressure (IOP) is the only modifiable factor in glaucoma management proven to alter the natural course of the disease. Among various classes of IOP-lowering medications currently available, alpha-adrenergic receptor agonists are used either as monotherapy, as second-line therapy, or in fixed combination with beta-blockers. Non-selective adrenergic agonists such as epinephrine and dipivefrin are infrequently used today for the treatment of glaucoma or ocular hypertension, and have been replaced by the alpha-2-selective agonists. The use of apraclonidine for IOP reduction in glaucoma or OHT is limited due to a high rate of follicular conjunctivitis. The alpha-2-selective agonist in use today is brimonidine. The brimonidine-purite formulations are preferred to brimonidine-benzalkonium chloride (BAC) formulations due better tolerability while maintaining similar efficacy. Brimonidine is also effective when used in combination with a beta-blocker. Using brimonidine-timolol fixed combination (BTFC) as first-line therapy has an added potential for neuroprotection. This would be a valuable strategy for glaucoma treatment, for patients who are intolerant of prostaglandin analogs, or for patients where prostaglandin analogues are contraindicated as first-line therapy, such as in patients with inflammatory glaucoma.

Fadolmidine-induced ocular hypotension in normotensive rabbits

Fadolmidine, a novel selective α-adrenoceptor agonist, was evaluated for its efficacy to lower intraocular pressure in normotensive rabbits (n = 5–6). The dose-response profile between 0.004 μg and 12.5 μg of fadolmidine was determined. The effect of pH on the partition of fadolmidine was studied in order to select an optimal pH for topical fadolmidine administration. After topical administration, fadolmidine significantly lowered the intraocular pressure in normotensive rabbits. The onset of action was immediate, with no initial increase in intraocular pressure. A significant decrease in intraocular pressure was already observed at 1 h after dosing. The maximum decrease in intraocular pressure was observed after a 2.5 μg dose of fadolmidine in both eyes at 2 h after dosing. The mean maximum decrease in the treated and untreated eye was 6.4 mmHg and 3.9 mmHg, respectively. In conclusion, fadolmidine is a potent intraocular pressure lowering agent. In addition, fadolmidine does not cause a significant initial increase in intraocular pressure. Because of the strong dependence of the distribution coefficient on pH, the pH of the administered solution is important, with physiological pH being optimal in this respect.

Brimonidine-purite 0.1% versus brimonidine-purite 0.15% twice daily in glaucoma or ocular hypertension: a 12-month randomized trial

OBJECTIVE

To compare the safety and intraocular pressure (IOP)-lowering effects of brimonidine-purite 0.1% with the marketed formulation of brimonidine-purite 0.15% (Alphagan P 0.15%) when used twice daily (BID) by patients with glaucoma or ocular hypertension previously treated with brimonidine-purite 0.15% for at least 6 weeks.

METHODS

In a 12-month, randomized, double-masked, multicenter, parallel group, non-inferiority study, patients with glaucoma or ocular hypertension who were treated with brimonidine-purite 0.15% BID were randomly assigned to continue brimonidine-purite 0.15% (n=102) or to administer brimonidine-purite 0.1% (n=105) BID for 12 months. IOP was measured at approximately 8 a.m. (hour 0) and 10 a.m. (hour 2).

MAIN OUTCOME MEASURES

Mean change from baseline IOP and adverse events.

RESULTS

Demographics and baseline characteristics were similar between treatment groups. Treated-baseline mean IOPs at both timepoints were similar between groups (p > or = 0.606). Brimonidine-purite 0.1% provided IOP-lowering that was non-inferior to brimonidine-purite 0.15% at each of the 12 follow-up timepoints, and there were no statistically significant between-group differences at any timepoint. The most commonly reported adverse event was conjunctival hyperemia (13.5% for brimonidine-purite 0.1%; 10.8% for brimonidine-purite 0.15%). No significant differences in the incidence of adverse events were noted between the two formulations.

CONCLUSIONS

Brimonidine-purite 0.1% BID is as effective as brimonidine-purite 0.15% BID in lowering IOP in patients with glaucoma or ocular hypertension who were previously treated with brimonidine-purite 0.15%, and both formulations are well tolerated. Limitations of the study include enrollment of only patients who were already on treatment with brimonidine-purite 0.15%. The 0.1% formulation of brimonidine-purite allows for decreased exposure to brimonidine while providing an IOP-lowering effect comparable to that of the 0.15% formulation. Clinical trial registered at clinicaltrials.gov; identifier: NCT00168363.

Brimonidine 0.2% versus brimonidine Purite 0.15% in Asian ocular hypertension

PURPOSE

The aim of this study was to evaluate the efficacy and safety of brimonidine 0.2% versus brimonidine Purite 0.15% in Asians with ocular hypertension.

METHODS

This study was a prospective, randomized, observer-masked, short-term crossover trial. Eighty-six (86) Asian subjects with newly diagnosed ocular hypertension were randomly assigned to receive either brimonidine 0.2% or brimonidine Purite 0.15%, both dosed twice a day for 4 weeks. Subjects were then washed out for 6 weeks and switched to the opposite treatment for 4 weeks.

RESULTS

The baseline intraocular pressure (IOP) was 24.4 +/- 2.45 mmHg for brimonidine 0.2% and 24.39 +/- 2.56 mmHg for brimonidine Purite 0.15% (P = 0.985). The IOP was at trough drug effect after 4 weeks of brimonidine 0.2% and brimonidine Purite 0.15% therapy were 20.10 +/- 2.01 mmHg and 21.00 +/- 1.67 mmHg (P = 0.001), respectively. The IOP at peak drug effect after 4 weeks of brimonidine 0.2% and brimonidine Purite 0.15% treatment were 18.10 +/- 1.73 mmHg and 18.20 +/- 1.71 mmHg (P = 0.518), respectively. Brimonidine 0.2% was found to cause more allergic conjunctivitis than brimonidine Purite 0.15% (P < 0.001).

CONCLUSIONS

Brimonidine 0.2% has a higher potency of lowering IOP than brimonidine Purite 0.15% at trough when used twice-daily. However, ocular allergic reaction was more frequent and severe with brimonidine 0.2% than with brimonidine Purite 0.15%.

Evolving Paradigms in the Medical Treatment of Glaucoma

In the last 5 years, numerous novel ocular hypotensive agents have been introduced for the control of intraocular pressure (IOP). Clinicians now have more options than ever in medical therapy for the treatment of glaucoma and ocular hypertension. When selecting an ocular hypotensive medication for their patients, clinicians should consider not only the IOP-lowering efficacy of an agent but also the ability of the drug to achieve target levels of IOP that are low enough to stop the progression of glaucomatous damage. Other considerations should include how well the drug controls diurnal IOP, the likelihood of serious adverse events, the versatility of the medication for use as an adjunctive agent, as well as other potential attributes (e.g., neuroprotection).

Efficacy of Bimatoprost 0.03 Percent in Untreated Glaucoma and Ocular Hypertension Patients: Results From a Large Community-Based Clinical Trial

PURPOSE

To evaluate the intraocular pressure- (IOP-) lowering efficacy of bimatoprost 0.03% (Lumigan, Allergan, Inc.) monotherapy in the treatment of patients with glaucoma or ocular hypertension not currently using ocular hypotensives.

METHODS

Open-label, community-based, multicenter evaluation. Patients (n = 6767) who, according to their physicians, required IOP lowering were prescribed bimatoprost for 2 months. Subgroup analyses of the results, stratified by treatment history and use of concomitant medications, were performed. This report focuses on the subgroup of patients that was not being treated with antiglaucoma medications at baseline (n = 1946, 29%). All of these patients were placed on bimatoprost monotherapy.

RESULTS

The mean IOP at the untreated baseline was 23.8 mmHg. Bimatoprost provided a mean IOP reduction of 7.5 mmHg (30%, p < 0.001) from baseline after 2 months of monotherapy. Further, bimatoprost allowed patients to achieve low target pressures. For example, 41.5% of patients achieved target IOPs of < or =15 mmHg after 2 months of bimatoprost monotherapy, and 75.8% of patients reached IOPs of < or =18 mmHg. The most commonly reported adverse event was conjunctival hyperemia (7.9%).

CONCLUSION

Bimatoprost monotherapy was well tolerated and reduced IOP by an average of 30% in a large population of untreated patients.

Evaluation of the comfort of Alphagan P compared with Alphagan in irritated eyes

The tolerability of brimonidine tartrate 0.15%--referred to as bromonidine-Purite 0.15% in this study--was compared with brimonidine tartrate 0.2% in irritated eyes of healthy volunteers as well as patients with glaucoma or ocular hypertension (N=20) in a 2-week, single-center, randomized, double-masked, crossover study. Participants were evaluated at days 0, 7, 11, and 15. At day 0, they were exposed to a controlled adverse environment (CAE), in which humidity, temperature, and airflow was regulated, for up to 90 minutes. Participants who reported a sufficient level of bilateral ocular discomfort during exposure to the CAE were enrolled in this study and received 1 drop of brimonidine-Purite 0.15% in 1 eye and 1 drop of brimonidine tartrate 0.2% in the contralateral eye. Immediately following instillation, participants were asked to indicate their preference for either study medication. The study medications were not used between days 0 and 7. From day 7 to 10, participants administered either drug bilaterally. On day 11, the treatment was crossed over, and participants were asked to compare the preferred medication with their previous regimen. They continued to administer the drug bilaterally twice daily until day 15, when the preferred medication was again compared with the previous regimen. Following CAE exposure at visit 1, 70.6% of the participants preferred brimonidine-Purite 0.15% over brimonidine tartrate 0.2% and indicated that it was significantly more comfortable than brimonidine tartrate 0.2% (P=.009). When given brimonidine-Purite 0.15% first before switching to brimonidine tartrate 0.2%, 80% of participants preferred brimonidine-Purite 0.15% (P=.012). When given brimonidine tartrate 0.2% first before switching to brimonidine-Purite 0.15%, 85% preferred brimonidine-Purite 0.15% (P=.001). The results of this study suggest that brimonidine-Purite 0.15% is significantly more comfortable than brimonidine tartrate 0.2% in patients with irritated eyes.

Ocular hypotensive efficacy of bimatoprost when used as a replacement for latanoprost in the treatment of glaucoma and ocular hypertension

PURPOSE

To evaluate the clinical effectiveness of bimatoprost (Lumigan, Allergan, Inc.) when used as a replacement for latanoprost (Xalatan, Pharmacia) in the treatment of glaucoma and ocular hypertension.

METHODS

This was a community-based, two-month, open-label, multicenter, trial. Patients with glaucoma or ocular hypertension who needed additional IOP lowering or who were intolerant of other glaucoma medications were placed on bimatoprost therapy (alone or in combination with other drugs at the physician's discretion).

RESULTS

This first report of the data from this study focuses on those patients for whom the physician chose to replace latanoprost therapy with bimatoprost therapy (n = 1283). After 2 months of bimatoprost therapy, the mean decrease in IOP was 3.4 mm Hg and many more patients had achieved low target pressures. The percentage of patients achieving a target pressure of < or =18 mm Hg doubled from 33% to 66% (P <.001). The percentage of patients achieving target pressures of < or =15 mm Hg and < or =14 mm Hg was approximately 3 to 4 times greater at the end of the study than the beginning; increasing from 11% to 36% and from 6% to 26%, respectively (P <.001). A subgroup analysis showed comparable improvements in IOP-control regardless of the previous treatment regimen or whether bimatoprost was used alone or in combination with other medications. The most commonly reported adverse event was conjunctival hyperemia (3.7%; 47/1283).

CONCLUSION

Bimatoprost therapy is well-tolerated and helps many more patients reach low target pressures when used as a replacement for latanoprost in a variety of treatment regimens.

A novel D2-dopaminergic and alpha2-adrenoceptor receptor agonist induces substantial and prolonged IOP decrease in normotensive rabbits

The effects of a novel and selective D2-dopaminergic/alpha2-adrenoceptor agonist, CHF1035, and its metabolite CHF1024 on intraocular pressure (IOP) were determined in rabbits. Because CHF1035 is a mixture of two enantiomers, CHF1800 (+) and CHF1810 (-), pure enantiomers were also studied to determine possible differences in IOP-decreasing ability depending on the stereochemistry of the molecule. CHF1035, CHF1800 (+), CHF1810 (-), CHF1024, brimonidine and 0.9% NaCl were administered topically to rabbits and IOP was then measured at fixed time intervals. The dose-response profile (0.01-1.0% w/v) was determined for CHF1035. CHF1035 and its metabolite CHF1024 significantly lowered IOP in the treated eyes. CHF1035 showed a maximum IOP decrease (7.6 +/- 1.5 mmHg) 5 h post-dosing, whereas the metabolite CHF1024 showed a maximum decrease in IOP (7.0 +/- 0.8 mmHg) 3 h post-dosing. The maximum IOP decrease produced by CHF1035 in the treated eye was comparable with that produced by brimonidine (7.8 +/- 0.9 mmHg), but CHF1035 had a significantly longer duration of action. Unlike brimonidine, CHF1035 and CHF1024 did not decrease IOP in the untreated eye. CHF1810 (-) lowered the IOP more than CHF1800 (+). No irritation, evaluated as eyelid closure, was observed after topical administration of any of the compounds. Only in the case of CHF1035 1% solution, two rabbits out of six closed the eye for 30-45 s. In conclusion, CHF1035 and its metabolite CHF1024 significantly decreased the IOP in rabbits, and are potential novel IOP lowering agents. Especially, CHF1035 produced a substantial decrease in IOP for a prolonged period of time, and thus may prove useful in glaucoma therapy.

Comparison of brimonidine/latanoprost and timolol/dorzolamide: two randomized, double-masked, parallel clinical trials

Two double-masked, randomized, parallel, multicenter trials of similar design were conducted to compare the IOP-lowering efficacy of dual therapy with brimonidine 0.2% and latanoprost 0.005% with the fixed combination of timolol 0.5%/dorzolamide 2% in patients with glaucoma or ocular hypertension. The combination of brimonidine and latanoprost produced significantly greater mean IOP reductions at each visit in both trials. In study 1, the mean reduction at peak drug effect after 6 weeks was 9.2 mm Hg (34.7%) with brimonidine and latanoprost and 6.7 mm Hg (26.1%) with timolol/dorzolamide (P=.024); respective reductions at week 12 were 9.0 mm Hg (33.9%) and 6.5 mm Hg (25.3%) (P=.044). At the month 1 visit in study 2, the mean peak IOP reduction was 10.6 mm Hg (39.0%) with dual therapy and 6.3 mm Hg (25.1%) with the fixed combination (P=.001). After 3 months, reductions were 9.1 mm Hg (33.4%) and 6.6 mm Hg (26.3%) (P=.047). In these studies, the combination of brimonidine and latanoprost provided IOP control superior to that of the fixed combination of timolol/dorzolamide.

A 3-month comparison of efficacy and safety of brimonidine-purite 0.15% and brimonidine 0.2% in patients with glaucoma or ocular hypertension

PURPOSE

To compare the efficacy and safety of brimonidine Purite 0.15% (ALPHAGAN P) BID with brimonidine 0.2% (ALPHAGAN) BID in patients with glaucoma or ocular hypertension.

METHODS

3-month, multicenter, randomized, double-masked trial. Eligible patients were taking brimonidine 0.2% BID for at least 6 weeks prior to study entry and their intraocular pressure (IOP) was < or = 21 mm Hg. Patients were randomly assigned to receive either brimonidine Purite 0.15% BID (n = 203) or brimonidine 0.2% BID (n = 204). Scheduled visits were prestudy, baseline, and weeks 2, 6 and 12. IOP was measured at hour 0 and hour 2 to evaluate efficacy. Safety was measured by monitoring adverse events. Patient satisfaction and comfort were also evaluated at all visits.

RESULTS

There was no statistically significant difference between the brimonidine 0.2% and brimonidine Purite 0.15% groups with respect to mean IOP at baseline. The IOP-lowering efficacy of brimonidine Purite 0.15% was equivalent to that of brimonidine 0.2% and both study treatments maintained IOP-lowering effects of brimonidine 0.2%. There were no significant between-group differences in mean IOP. The differences in the mean IOPs were < or = 0.26 mm Hg and the mean change from baseline IOP was < or = 0.35 mm Hg at all follow-up time points. There were no statistically significant differences between the two groups in the overall incidence of adverse events. The most commonly reported treatment-related adverse events were conjunctival hyperemia and allergic conjunctivitis: both were mild in severity.

CONCLUSION

Brimonidine Purite 0.15% dosed BID provides equal IOP-lowering efficacy to brimonidine 0.2% BID. Patients previously controlled on brimonidine 0.2% can be successfully switched to brimonidine Purite 0.15%.

Brimonidine Purite and bimatoprost compared with timolol and latanoprost in patients with glaucoma and ocular hypertension

This 3-month multicenter, investigator-masked, parallel-group study compared brimonidine Purite and bimatoprost (brimP/bim) with timolol gel-forming solution and latanoprost (tim/latan) in 28 patients with open-angle glaucoma or ocular hypertension. IOP was measured at baseline and 2 hours after morning instillation at weeks 2, 4, and 12. The primary outcome measure was the mean IOP reduction from baseline. Secondary measures were the percentage of patients in each group who achieved specific low target pressures and the incidence of adverse events. Mean IOP at baseline was 24.8 mm Hg in each group. At follow-up visits, mean reductions from baseline ranged from 8.5 to 9.0 mm Hg with brimP/bim and from 7.5 to 7.7 mm Hg with tim/latan. More patients achieved low target pressures with brimP/bim. At week 12, 69.2% of brimP/bim patients and 27.3% of tim/latan patients had IOPs of 16 mm Hg or lower (P = .024). Both regimens were well tolerated, and adverse events were infrequent. The combination of brimonidine Purite and bimatoprost was well tolerated and at least as effective as Timoptic-XE and latanoprost in reducing IOP. More patients achieved low target IOPs with brimonidine Purite and bimatoprost than with Timoptic-XE and latanoprost. A larger study is needed to confirm these results.

Twelve-month evaluation of brimonidine-purite versus brimonidine in patients with glaucoma or ocular hypertension

PURPOSE

To compare the efficacy and safety of brimonidine-Purite (Alphagan; Allergan, Irvine, CA) 0.15% and 0.2% three times daily with brimonidine (Alphagan) 0.2% three times daily in patients with glaucoma or ocular hypertension.

PATIENTS AND METHODS

In this 12-month, randomized, multicenter, double-masked, parallel-group study, patients were randomly assigned to receive brimonidine-Purite 0.15% (n = 381), brimonidine-Purite 0.2% (n = 383), or brimonidine 0.2% (n = 383) three times daily. Visits were conducted before the study, at baseline, at weeks 2 and 6, and at months 3, 6, 9, and 12. Diurnal intraocular pressure was measured at 8 am, 10 am, 3 pm, and 5 pm at baseline, week 6, and at months 3, 6, and 12. Intraocular pressure was also measured at 8 and 10 am at week 2 and month 9. Safety was evaluated by adverse events and other ocular and systemic measures.

RESULTS

At baseline, mean intraocular pressure was similar in the three treatment groups. During follow-up, there were no statistically significant among-group differences in mean intraocular pressure or mean changes from baseline intraocular pressure (at peak or trough). The difference in mean intraocular pressure between the brimonidine-Purite-0.15% and brimonidine-0.2% treatment group was less than 1 mm Hg at all time points. The relative percent difference in allergic conjunctivitis was 41% lower in the brimonidine-Purite 0.15% group compared with the brimonidine 0.2% group. The comfort and satisfaction rating significantly favored brimonidine-Purite 0.15%.

CONCLUSIONS

Over 12-months, brimonidine-Purite 0.15% and 0.2% provided intraocular pressure lowering comparable with brimonidine 0.2% in patients with glaucoma or ocular hypertension. Brimonidine-Purite 0.15% showed the most favorable safety and tolerability profile with a reduced incidence of allergic conjunctivitis and better satisfaction and comfort rating.

Brimonidine .2% as a replacement for beta blockers in geriatric patients with glaucoma

This 3-month multicenter, open-label study of 89 geriatric patients with glaucoma evaluated the substitution of brimonidine twice daily for topical beta blockers that had been used for at least 6 months. The primary outcome measures were reduction in intraocular pressure (IOP) from baseline at 2 hours postdose, change in cardiac and respiratory function, quality of life, and patient satisfaction. Patients were queried about adverse events at each visit and completed a quality-of-life questionnaire at the final evaluation. In this cohort with a mean age of 75.4 years, the average duration of topical beta-blocker therapy was 5 years. Brimonidine twice daily produced an additional mean reduction in IOP of 8.2% (1.4 mm Hg; P<.001). Eighty-eight percent of patients (60/68) reported being at least as satisfied with brimonidine as with their previous beta-blocker regimen, and 46% (31/68) reported greater satisfaction with brimonidine. Additionally, 40% of patients (27/68) noted increased energy after the switch, and 43% (29/68) described brimonidine as more soothing than topical beta blockers. In this elderly population, the replacement of topical beta blockers with brimonidine twice daily significantly decreased IOP, improved quality of life, and enhanced patient satisfaction.

Three-month comparison of brimonidine and latanoprost as adjunctive therapy in glaucoma and ocular hypertension patients uncontrolled on beta-blockers: tolerance and peak intraocular pressure lowering

PURPOSE

To compare the tolerance and peak intraocular pressure (IOP)-lowering efficacy of brimonidine and latanoprost as adjunctive therapy in patients with ocular hypertension or glaucoma uncontrolled on beta-blockers.

DESIGN

A prospective, multicenter, double-masked, parallel-design clinical trial.

PARTICIPANTS

One hundred fifteen patients with IOP inadequately controlled on topical beta-blocker monotherapy.

METHODS

Patients were randomly assigned to receive brimonidine, 0.2%, twice a day or latanoprost, 0.005%, every day as adjunctive therapy for 3 months. After 1 month of adjunctive treatment, patients who failed to meet a target 15% reduction in IOP at peak drug effect were crossed over to the other study medication. The target sample size of 51/group gave a power of 0.80 to detect a difference of 1 mmHg in mean IOP lowering between groups.

MAIN OUTCOME MEASURES

The primary outcome variables were reduction in IOP from baseline at peak drug effect, response rate, and quality of life as measured using the Glaucoma Disability Index.

RESULTS

Mean beta-blocker-treated baseline IOP was comparable between treatment groups (approximately 21.3 mm Hg). After 1 month of adjunctive therapy, brimonidine and latanoprost provided comparable IOP lowering (4.88 mmHg [22.8%] with brimonidine and 5.01 mmHg [23.5%] with latanoprost, P = 0.798). Response rates were similar in both groups, with 44 of 54 brimonidine patients and 43 of 53 latanoprost patients achieving the minimum target 15% IOP reduction at peak drug effect at month 1 (P = 0.963). Among patients who were successful at month 1 and continued on the initial study medication, mean IOP reductions were 4.55 mmHg with brimonidine and 5.49 mmHg with latanoprost (P = 0.149) at month 3. There was no significant difference in the ability of brimonidine and latanoprost to maintain at least a 15% additional reduction in IOP for 3 months (28 of 38 patients on brimonidine vs. 30 of 36 patients on latanoprost achieved > or =15% IOP reduction at month 3; P = 0.314). Patients in the latanoprost group were more likely to report negative quality-of-life variables than patients in the brimonidine group. Significantly more latanoprost patients reported watery or teary eyes (34 of 53, 64.2% vs. 23 of 54, 42.6% with brimonidine; P = 0.025) and hands and feet that became cold easily (24 of 53, 45.3% vs. 12 of 54, 22.2% with brimonidine; P = 0.012).

CONCLUSIONS

As adjunct therapy with beta-blockers, brimonidine twice daily and latanoprost every day were comparable in lowering IOP at peak effect, but brimonidine was better tolerated, with fewer reports of adverse quality-of-life effects.

A comparison of the efficacy and tolerability of brimonidine and latanoprost in adults with open-angle glaucoma or ocular hypertension: a three-month, multicenter, randomized, double-masked, parallel-group trial

BACKGROUND

Many physicians recommend either brimonidine or latanoprost as firstline therapy for chronic open-angle glaucoma or ocular hypertension. However, a search of MEDLINE indicates that there have been few head-to-head comparisons of the 2 monotherapies in a clinical setting.

OBJECTIVE

This study compared the clinical efficacy and tolerability of brimonidine 0.2% twice daily with those of latanoprost 0.005% once daily as monotherapy in patients with open-angle glaucoma or ocular hypertension.

METHODS

In this 3-month, multicenter, double-masked, parallel-group, 4-visit study, treatment-naive and previously treated patients with open-angle glaucoma or ocular hypertension and bilateral intraocular pressure (IOP) after washout of between 22 and 34 mm Hg were randomized to receive either brimonidine or latanoprost. Patients who had received previous treatment with either study drug were excluded from the study. The primary outcome measure was response rate, defined as the percentage of patients achieving > or = 20% reduction in IOP from baseline to month 3. Secondary outcome measures were mean IOP reduction from baseline to month 3 and clinical success, defined as the investigator's recommendation that the patient continue using the assigned study medication.

RESULTS

A total of 127 patients (55 treatment naive) were enrolled, 66 in the brimonidine group and 61 in the latanoprost group. After 3 months of treatment, 80% of patients in the brimonidine group and 74% of patients in the latanoprost group had achieved > or = 20% reduction in IOP from baseline. The mean reduction in IOP from baseline at month 3 was 6.8 mm Hg with brimonidine and 6.5 mm Hg with latanoprost (27.8% vs 27.0%, respectively). Among treatment-naive patients, a significantly higher percentage of brimonidine-treated patients achieved > or = 20% decrease in IOP compared with latanoprost-treated patients (88% vs 59%, respectively; P = 0.01). In previously treated patients, a higher percentage of the latanoprost group achieved > or = 20% reduction in IOP compared with the brimonidine group (88% vs 74%, respectively); however, the difference was not statistically significant. Significantly more patients in the brimonidine group achieved clinical success at month 3 compared with patients in the latanoprost group (91% vs 74%; P = 0.01).

CONCLUSIONS

At peak effect, brimonidine twice daily was as effective as latanoprost once daily in lowering IOP. In treatment-naive patients, latanoprost was associated with a significantly higher rate of nonresponse after 3 months of treatment compared with brimonidine. This suggests that brimonidine may be the more reliable choice for first-line therapy of newly diagnosed open-angle glaucoma or ocular hypertension. In previously treated patients, however, latanoprost provided greater mean IOP reduction than did brimonidine. Significantly more patients achieved clinical success with brimonidine monotherapy than with latanoprost monotherapy.

Switching patients with glaucoma or ocular hypertension from dual therapy to monotherapy: evaluation of brimonidine as a model

A multicenter open-label study investigated the clinical effectiveness and economic feasibility of switching 142 patients from dual therapy to twice-daily monotherapy with brimonidine for glaucoma or ocular hypertension. Evaluations were performed at baseline and 2 (visit 2) and 8 (visit 3) weeks after the switch. Patients completed a questionnaire that rated medication-related visual function and satisfaction (comfort, convenience, vision, ease of remembering to use drops) at each visit. At visit 3, investigators, taking into account IOP measurements, safety, and responses on the questionnaire, recommended whether the patient should remain on brimonidine. A pharmacoeconomic analysis, including the number of visits, cost of medication, and success rates, compared the cost of dual therapy with that of switching to brimonidine monotherapy. Of the 131 patients who completed the study, 77 (59%) had no change or a decrease in IOP from baseline, and 53 (41%) had an increase. Investigators recommended that 77% of the study completers continue to take brimonidine monotherapy. Extending treatment with brimonidine for 12 months would achieve a significant cost savings of 16%. Brimonidine monotherapy is an efficacious and cost-effective alternative to dual therapy for glaucoma and ocular hypertension. Appropriate monotherapy may be as effective as dual therapy for many patients, and a clinically relevant trial such as this may be economically advantageous for testing a switch.

Safety and efficacy of brimonidine in children with glaucoma

PURPOSE

Brimonidine is a relatively selective alpha-agonist, which reduces intraocular pressure (IOP) by decreasing aqueous production and increasing uveoscleral outflow. Brimonidine passes through the blood-brain barrier, potentially causing central nervous system (CNS) toxicity. There have been reports of bradycardia, hypotension, hypothermia, hypotonia, and apnea in infants after topical brimonidine.

METHODS

We reviewed the IOP data and side effects of children at the Duke University Eye Center placed on brimonidine from June 1997 to October 2000. Brimonidine 0.2% was used for patients whose glaucoma was uncontrolled on maximal tolerated medical therapy. A monocular trial was performed whenever possible, and brimonidine was not prescribed for infants. Included were 32 eyes of 30 patients with uncontrolled IOP and varied glaucoma diagnoses.

RESULTS

The mean patient age was 10.5 years, with a mean follow-up on brimonidine of 10.8 months. Most patients were on other glaucoma medications. In 11 of the 32 eyes the IOP data could be interpreted, and in these eyes the IOP decreased from a mean of 22.5 +/- 4.9 mm Hg to a mean of 20.8 +/- 4.0 mm Hg (a mean decrease of 6.7% +/- 10%, P =.04) on brimonidine after a mean follow-up of 11.0 +/- 6.9 months. Two young children (ages 2.4 and 3.7 years) repeatedly were unarousable soon after the administration of brimonidine. Five other children experienced extreme fatigue after brimonidine administration. All symptoms resolved after brimonidine was discontinued.

DISCUSSION/CONCLUSIONS

Brimonidine should be used with caution in young children because of the potential for CNS depression. In selected patients, brimonidine has a substantial ocular hypotensive effect.

Effectiveness and safety of brimonidine as adjunctive therapy for patients with elevated intraocular pressure in a large, open-label community trial

PURPOSE

To determine the effectiveness and safety of brimonidine when used in combination with one or more glaucoma medications in patients with glaucoma or ocular hypertension.

METHODS

Post hoc analysis of a multicenter, 2-month, open-label, prospective, clinical trial in which 2,335 patients received brimonidine as monotherapy, replacement therapy, or combination therapy. Patients who received brimonidine as combination therapy (n = 554) were examined in the current analysis. Efficacy was determined by the reduction in intraocular pressure (IOP) from baseline before the addition of brimonidine. Safety and tolerability parameters included adverse events and quality-of-life measures (e.g., ocular comfort, energy level, breathing ability, night vision).

RESULTS

Addition of brimonidine to preexisting regimens resulted in an overall mean additional reduction in IOP of 17.9% (4.26 mm Hg) at month 2 (P < 0.001). Significant additional IOP lowering was provided by brimonidine in combination with each preexisting regimen evaluated (P < or = 0.061). When brimonidine was added to monotherapy with a nonselective beta-blocker, the mean additional IOP reduction was 15.5% (3.61 mm Hg, P < 0.001). Addition of brimonidine to latanoprost monotherapy provided a 32.2% (5.89 mm Hg) mean additional IOP reduction (P < 0.001). Addition of brimonidine to combination regimens that included latanoprost provided additional mean decreases in LOP ranging from 15.5% (3.63 mm Hg, P < 0.002) to 20.1% (6.62 mm Hg, P < 0.001). All quality-of-life parameters remained high or improved during the study. Mild to moderate adverse events were reported in 5.23% of patients (29 of 552); 98.1% of physicians rated brimonidine adjunctive therapy as good or excellent.

CONCLUSIONS

Brimonidine, when added to existing glaucoma regimens, safely and effectively lowered IOP in this community-based trial.

Efficacy of brimonidine as replacement therapy in patients with open-angle glaucoma or ocular hypertension

BACKGROUND

Patients with glaucoma or ocular hypertension may have inadequately controlled intraocular pressure (IOP) or experience adverse effects with their current medication regimens.

OBJECTIVE

This post hoc reanalysis determined the effectiveness and tolerability of brimonidine used as replacement therapy in a real-life clinical practice setting.

METHODS

In this multicenter, open-label, observational, 2-month study, 460 patients received brimonidine 0.2% as a 1:1 replacement for another antiglaucoma medication in their current regimen. Effectiveness was assessed by calculating the mean additional reduction in IOP from the treated baseline measurement (before the switch to brimonidine) to 2 months postbaseline, and by determining physicians' opinions of treatment effectiveness. Tolerability was determined based on quality-of-life assessments and recorded adverse events.

RESULTS

Overall, brimonidine replacement significantly reduced mean (+/- SEM) IOP by an additional 2.33 +/- 0.17 mm Hg (9.8% +/- 0.9%; P < 0.001). Significant additional reductions in IOP were seen when brimonidine replaced an agent used either as monotherapy or adjunctive therapy, regardless of the drug class of the agent replaced. However, particularly good hypotensive effectiveness and additional lowering of IOP were observed when brimonidine replaced certain medications, including latanoprost (12.44%; P < 0.003) and betaxolol (13.56%; P < 0.001) monotherapy, and latanoprost (16.08%; P < 0.010) adjunctive therapy. The effectiveness of brimonidine was rated as good or excellent by 92.4% of physicians. All quality-of-life variables remained favorable or improved throughout the study, and brimonidine treatment was well tolerated.

CONCLUSIONS

Brimonidine 0.2% used as a 1:1 replacement for monotherapy or adjunctive therapy with other antiglaucoma drugs significantly lowered IOP from that produced by previous therapy and was well tolerated. Brimonidine offers a useful treatment option in patients who require replacement therapy.