The Systemic Safety of Bromfenac Ophthalmic Solution 0.09%

Topical 0.1% Nepafenac versus 0.09% Bromfenac Eye Drops for Inflammation after Laser Peripheral Iridotomy: A Randomized Controlled Trial

PURPOSE

To assess the safety and efficacy of 0.1% nepafenac versus 0.09% bromfenac eye drops in controlling inflammation after neodymium yttrium-aluminum-garnet (YAG) laser peripheral iridotomy (LPI).

DESIGN

Single-masked, single-center, randomized controlled trial.

PARTICIPANTS

One hundred and sixty eyes of patients with primary angle-closure suspect (PACS) and primary angle closure (PAC) undergoing bilateral LPI.

METHODS

Patients were randomized in a 1:1 ratio to receive 0.1% nepafenac thrice daily or 0.09% bromfenac eye drops twice daily for 2 weeks after neodymium YAG LPI. Assessment was performed by masked investigators at 2 weeks after LPI. A Glaucoma Symptom Scale (GSS) questionnaire was administered both at baseline and 2 weeks after LPI. Subjective comfort scores to the study medications were assessed on the basis of a Likert scale at 2 weeks after LPI. In patients with bilateral PACS or PAC, the right eye was analyzed, and in asymmetrical disease (i.e., when one eye had PACS and the other eye had PAC), the eye with PAC was analyzed.

MAIN OUTCOME MEASURES

The primary outcome (end point) was uncontrolled inflammation, defined as symptomatic inflammation within 1 week after LPI, the presence of anterior chamber cells at 2 weeks, or rebound inflammation after medication discontinuation. The secondary outcome was patient-reported comfort levels with study medications based on the GSS and Likert scale.

RESULTS

At 2 weeks after LPI, 7 patients (6 with PACS and 1 with PAC) in the nepafenac group and 2 patients with PACS in the bromfenac group achieved the primary end point, without a difference between the medication groups (P = 0.09). Post-LPI burning, smarting, and stinging was more common in the bromfenac group (P = 0.01), which also had a higher comfort score on the Likert scale (P = 0.004). The need for repeat LPI was comparable (10.0% in the nepafenac group vs. 15.4% in the bromfenac group; P = 0.22). A multivariate analysis revealed that a greater number of laser shots was associated with the need for repeat LPI (odds ratio, 1.05; 95% confidence interval, 1.00-1.10; P = 0.04).

CONCLUSIONS

Topical 0.09% bromfenac is noninferior to 0.1% nepafenac in controlling inflammation after LPI in eyes with PACS and PAC. Nepafenac may be associated with higher patient-reported comfort.

Cataract surgery and nonsteroidal antiinflammatory drugs

Nonsteroidal antiinflammatory drugs (NSAIDs) have become an important adjunctive tool for surgeons performing routine and complicated cataract surgery. These medications have been found to reduce pain, prevent intraoperative miosis, modulate postoperative inflammation, and reduce the incidence of cystoid macular edema (CME). Whether used alone, synergistically with steroids, or for specific high-risk eyes prone to the development of CME, the effectiveness of these medications is compelling. This review describes the potential preoperative, intraoperative, and postoperative uses of NSAIDs, including the potency, indications and treatment paradigms and adverse effects and contraindications. A thorough understanding of these issues will help surgeons maximize the therapeutic benefits of these agents and improve surgical outcomes.

FINANCIAL DISCLOSURE

Proprietary or commercial disclosures are listed after the references.

Bromfenac Eyedrops in the Treatment of Diabetic Macular Edema: A Pilot Study

Purpose

To evaluate the efficacy and safety of topical bromfenac in patients with newly diagnosed diabetic macular edema (DME).

Methods

In this pilot study including 17 patients with monocular, newly diagnosed DME, diagnosis of DME was established by the detection of retinal thickening at or within 500 μm of the center of the macula on ophthalmoscopic examination, according to the Early Treatment Diabetic Retinopathy Study classification. Central macular thickness (CMT) was determined by optical coherence tomography. Bromfenac sodium hydrate 0.9 mg/mL eyedrops were administered in the affected eye twice daily for 30 days. Primary endpoints were changes in best-corrected visual acuity (BCVA) and CMT at the end of therapy.

Results

Topical bromfenac significantly reduced mean CMT, from 465.41 ± 118.47 μm at baseline to 388.88 ± 152.63 μm posttreatment (p = 0.02). There was no significant change in BCVA and differences in mean macular volume fell just short of statistical significance (p = 0.06). Treatment was well-tolerated, and there were no topical or systemic side effects.

Conclusions

Topical bromfenac twice daily may play a role in the reduction of DME. These preliminary results warrant further larger multicenter studies to confirm our findings and establish whether topical bromfenac may be of long-term benefit in the treatment of DME.

Recovery after cataract surgery

Cataract surgery is the most common ophthalmological surgical procedure, and it is predicted that the number of surgeries will increase significantly in the future. However, little is known about the recovery after surgery. The first aim of this study was to evaluate the prevalence, severity and duration of pain and other ocular discomfort symptoms experienced after cataract surgery. The other objectives were to identify the factors associated with lower postoperative patient satisfaction and to measure the effect of cataract surgery on patients' health-related quality of life (HRQoL) and visual function in everyday life. The study design was a prospective follow-up study. The course of the recovery and the presence of ocular symptoms were evaluated by interviewing the patients via a questionnaire at 1 day, 1 week, 6 weeks and one year after surgery The visual functioning in everyday life was measured with Visual Functioning Index VF-7 and Catquest-9SF-questionnaires and furthermore the HRQoL was measured with the 15D-instrument before surgery and at 12 months after surgery. The patients returned the questionnaires by mail and were interviewed in the hospital on the day of the surgery. The same patients filled-in all the questionnaires. The patient reports were used to collect the data on medical history. A total of 303 patients were approached at Kuopio University Hospital in 2010-2011 and of these 196 patients were eligible and willing to participate, with postoperative data being available from 186 (95%) patients. A systematic review article was included in the study procedure and it revealed the wide range in the reported incidence of postoperative ocular pain. Some of the identified randomized controlled studies reported no or only minor pain whereas in some studies significant pain or pain lasting for several weeks has been described in more than 50% of the study patients. In the present study setting, pain was reported by 34% during the first postoperative hours and by approximately 10% of patients during the first six weeks after surgery. During the early recovery in the hospital, only a minority of the patients reporting pain were provided with pain medication. The ocular discomfort symptoms such as itchiness, burning, foreign-body sensation and tearing were common both before (54%) and after surgery (38-52%). These symptoms can also be described as painful symptoms and are often difficult to distinguish from ocular pain. The symptoms are also typical of ocular surface disease, and some patients may benefit from the postoperative administration of tear substitutes. The patients reporting postoperative ocular symptoms were less satisfied with the treatment outcome at 12 months after surgery (p = 0.001) compared to the patients who experienced no symptoms. Those patients reporting less disability in visual functioning before surgery were more satisfied than patients with more reported disability. The HRQoL improved significantly after cataract surgery (p = 0.002). However, when compared to an age-and gender-standardized control population, in cataract subjects the HRQoL remained slightly worse both before and at 12 months after surgery.

Topical bromfenac for post-cataract extraction: A systematic review and pooled analysis

Bromfenac, a promising ophthalmic non-steroidal anti-inflammatory drug, has been used once daily for postoperative ocular inflammation and pain with satisfying efficacy, however, no integrated conclusion on its safety in clinical settings has been drawn. The purpose of this pooled analysis is to investigate the safety and efficacy of once daily bromfenac for ocular inflammation and pain among patients after cataract extraction (CE). MEDLINE, PsycINFO, Scopus, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to September 2014. Randomized controlled trials (RCTs) that studied topical bromfenac after CE were analyzed. Included studies were systemically reviewed, and effects were summarized using odds ratio (OR) with suitable effect model. Four RCTs involving 2294 participants were included. Topical bromfenac significantly increased the proportion of cleared ocular inflammation (OR, 2.37; 95% confidence interval [CI], 1.83–3.07; P <0.00001), ocular pain free (OR, 5.14; 95% CI, 4.07–6.49; P <0.00001), and decreased risk of overall adverse events (OR, 0.47; 95% CI, 0.38–0.58; P <0.00001). Bromfenac has been shown to be a safe and effective treatment for postoperative pain and inflammation in subjects undergoing CE. This is evidenced by the lower incidence of adverse events and the low scores for ocular pain and inflammation across multiple RCTs. However, demographics, co-morbidities of study participants, and the amount of co-medication were not reported, these possible sources of heterogeneity should be examined in future clinical trials.

Comparing the Efficacy of Ophthalmic NSAIDs in Common Indications

Objective: To review the commercially available ophthalmic nonsteroidal anti-inflammatory drugs (NSAIDs), identify opportunities for therapeutic substitutions within and outside of their Food and Drug Administration (FDA)-approved indications, and identify clinically superior drugs within the class for specific indications. Data Source: A PubMed search (1992 through January 2014) was performed on the terms diclofenac, ketorolac, flurbiprofen, bromfenac, and nepafenac. Study Selection and Data Extraction: Clinical trials, meta-analyses, and review articles were evaluated if they were written in English and pertained to human subjects. Studies were excluded if they were in vitro studies, solely evaluated pharmacokinetic or pharmacodynamic properties, did not relate to the topical ophthalmic route, did not evaluate the FDA-approved indications of any available ophthalmic NSAID, or compared a reviewed drug with a nonreviewed drug (without placebo comparison). Data Synthesis: A total of 67 articles met the criteria for evaluation. Article quality, study design, and dosing of the medications were assessed to determine the clinical applicability of the results. The quality of the article was determined using the Oxford Centre for Evidence-based Medicine Levels of Evidence 1. Conclusions: Many formulations of the 5 reviewed NSAIDs have been studied across the 4 primary indications. These indications are (1) pain and inflammation associated with cataract surgery, (2) pain associated with corneal refractive surgery, (3) inhibition of intraoperative miosis, and (4) seasonal allergic conjunctivitis. Several studies have directly compared drugs within this class and have identified instances in which certain selections are therapeutically superior or equivalent to another. This information provides practitioners with guidance in selecting an optimal medication.

Efficacy of COX-2 inhibitors in controlling inflammation and capsular opacification after phacoemulsification cataract removal

OBJECTIVE

To evaluate the efficacy of 0.9% bromfenac (Xibrom™) or a celecoxib-impregnated intraocular lens (celecoxib-IOL) compared with 1% prednisolone acetate (PA) in controlling postoperative inflammation and posterior capsule opacification (PCO).

ANIMAL STUDIED

Fifty-nine dogs undergoing cataract extraction by phacoemulsification.

PROCEDURE

Bilateral patients received bromfenac or celecoxib-IOL plus PA in one eye, and PA in the contralateral eye. Unilateral patients received bromfenac or PA. Complete ophthalmic examination including tonometry, slit-lamp grading of flare and PCO, and digital image acquisition for masked PCO evaluation was performed within 24 h and 1, 4, 12, 24, and 56 weeks following surgery.

RESULTS

Celecoxib-IOL/PA-treated eyes had significantly less flare than PA-treated eyes, which had significantly less flare than bromfenac-treated eyes 24 h postoperatively. There was no significant difference in intraocular pressure (IOP) postoperatively, or at 1, 24, or 56 weeks. Celecoxib-IOL/PA-treated eyes had significantly lower IOP measurements than bromfenac and PA-treated eyes at 4 and 12 weeks. There was no significant difference in PCO level between groups using slit-lamp biomicroscopy at any time point. Masked evaluation of digital images revealed significantly less PCO in celecoxib-IOL/PA- vs. bromfenac-treated eyes at 4 weeks, and in bromfenac- vs. PA-treated eyes at 56 weeks.

CONCLUSIONS

Eyes receiving celecoxib-IOL/PA had better initial control of inflammation. Bromfenac was equally effective compared with PA in controlling inflammation. There was no association between COX-2 inhibitor administration and ocular hypertension. Celecoxib-IOL/PA-treated eyes showed better initial control of PCO (up to 12 weeks), while eyes receiving bromfenac had better long-term control of PCO (56 weeks).

Postoperative pain after cataract surgery

Cataract extraction surgery is the most common surgical procedure, but knowledge of postoperative pain related to cataract surgery is sparse. In this systematic review, the incidence, prevalence, and management of pain after phacoemulsification surgery were identified using PubMed and Scopus. Selected studies were restricted to randomized controlled trials with interventions on postoperative inflammation and pain. Data from 105 articles were extracted and 21 studies met the final inclusion criteria. Most studies reported no or only mild postoperative pain, but some reported moderate and severe pain and pain lasting several weeks. The interventions consisted of drug therapy including topical nonsteroidal antiinflammatory drugs, corticosteroids, paracetamol, perioperative intraocular injections, eye pads used after surgery, and various surgical techniques. The reviewed literature indicates that cataract surgery is associated with significant postoperative pain in some patients, who should be provided with appropriate counseling and pain treatment.

Once daily dosing of bromfenac ophthalmic solution 0.09% for postoperative ocular inflammation and pain

OBJECTIVE

To evaluate the efficacy and ocular safety of bromfenac ophthalmic solution 0.09% dosed once daily for the treatment of ocular inflammation and pain following cataract extraction with posterior chamber intraocular lens implantation.

METHODS

A total of 455 subjects (455 study eyes: 230 bromfenac, 225 placebo) were enrolled in two randomized double-masked, placebo-controlled, clinical trials at 64 ophthalmology clinics in the United States. Subjects were randomized to receive either bromfenac 0.09% or placebo dosed once daily. Dosing began 1 day before cataract surgery (Day -1), continued on day of surgery (Day 0), and for 14 days following surgery. Evaluations were completed on Days 1, 3, 8, 15 and 22. The primary efficacy endpoint was cleared summed ocular inflammation score (SOIS) by Day 15. The secondary efficacy endpoint was the number of subjects who were pain-free at Day 1.

RESULTS

The bromfenac 0.09% group was significantly higher compared to the placebo group in the primary endpoint of the proportion of subjects who had cleared ocular inflammation by Day 15 (P < 0.0001). The mean SOIS for the bromfenac 0.09% group was lower than the placebo group at Days 3, 8, 15, and 22 (P < 0.0001). More bromfenac 0.09% subjects were pain free at Days 1, 3, 8, and 15 (P < 0.0001). Fewer subjects in the bromfenac 0.09% group withdrew from the clinical trials due to lack of efficacy at Day 15 (P < 0.0001). Fewer adverse events were reported in the bromfenac 0.09% group than the placebo group. Limitations included advanced age, female predominance, and surgical nuances among cataract surgeons, making cross-trial comparisons difficult.

CONCLUSIONS

Bromfenac ophthalmic solution 0.09% dosed once daily is clinically safe and effective for the treatment of ocular inflammation and the reduction of ocular pain associated with cataract surgery.

Safety and efficacy of bromfenac ophthalmic solution (Bromday) dosed once daily for postoperative ocular inflammation and pain

PURPOSE

To evaluate the efficacy and ocular safety of bromfenac ophthalmic solution (bromfenac) 0.09% dosed once daily for the treatment of ocular inflammation and pain after cataract surgery with posterior chamber intraocular lens implantation.

DESIGN

Randomized, double-masked, vehicle-controlled or active-controlled, multicenter, clinical trials.

PARTICIPANTS AND CONTROLS

A total of 872 subjects (872 study eyes: bromfenac in 584, placebo in 288).

METHODS

Four randomized, double-masked, vehicle or active-controlled, clinical trials were conducted at 134 ophthalmology clinics in the United States. Subjects aged ≥ 18 years were randomized to receive either bromfenac 0.09% or placebo dosed once daily beginning 1 day before cataract surgery (day -1), continuing on the day of surgery (day 0), and continuing for an additional postoperative 14 days. Subjects were evaluated for efficacy and safety on days 1, 3, 8, 15, and 22. The primary efficacy end point was cleared ocular inflammation, measured by the summed ocular inflammation score (SOIS; anterior chamber cells and flare) by day 15. The secondary efficacy end point was the number of subjects who were pain-free at day 1. The data from the 4 trials were pooled for analyses.

MAIN OUTCOME MEASURES

The SOIS and ocular pain.

RESULTS

The proportion of subjects who had cleared ocular inflammation by day 15 was significantly higher in the bromfenac 0.09% group than in the placebo group (P < 0.0001). The mean SOIS in the bromfenac 0.09% group was significantly lower than in the placebo group at days 3, 8, 15, and 22 (P < 0.0001). The proportion of subjects who were pain-free at days 1, 3, 8, and 15 was significantly higher in the bromfenac 0.09% group than in the placebo group (P < 0.0001). The incidence of adverse events reported in the bromfenac 0.09% group was significantly lower than in the placebo group (P < 0.0001). On day 15, 84.0% of the bromfenac subjects had ≥ 1-line improvement in visual acuity compared with 66.1% of placebo subjects (P < 0.0001).

CONCLUSIONS

Bromfenac 0.09% dosed once daily was clinically safe and effective for reducing and treating ocular inflammation and pain associated with cataract surgery.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Nonsteroidal anti-inflammatory drugs in ophthalmology

Nonsteroidal anti-inflammatory drugs (NSAIDs) are increasingly employed in ophthalmology to reduce miosis and inflammation, manage scleritis, and prevent and treat cystoid macular edema associated with cataract surgery. In addition, they may decrease postoperative pain and photophobia associated with refractive surgery and may reduce the itching associated with allergic conjunctivitis. In recent years, the U.S. Food and Drug Administration has approved new topical NSAIDs, and previously approved NSAIDs have been reformulated. These additions and changes result in different pharmacokinetics and dosing intervals, which may offer therapeutic advantages. For example, therapeutic effects on diabetic retinopathy and age-related macular degeneration may now be achievable. We provide an updated review on NSAIDs and a summary of their current uses in ophthalmology with attention to potential future applications.

Management of ocular inflammation and pain following cataract surgery: focus on bromfenac ophthalmic solution

Recently, several new ophthalmic NSAID products have been introduced for commercial use in the United States. The purpose of this review is to briefly overview the ophthalmic NSAIDs currently in use and to discuss the management of postoperative ocular inflammation and pain following cataract surgery with a particular focus on bromfenac ophthalmic solution 0.09%. Bromfenac ophthalmic solution 0.09% is indicated for the reduction of ocular pain and inflammation following cataract surgery. Studies have shown that bromfenac ophthalmic solution 0.09% has equivalent efficacy to the other topical NSAIDs in reducing postsurgical inflammation and controlling pain. The unique chemical structure of bromfenac makes it both a potent inhibitor of the COX-2 enzyme and a highly lipophilic molecule that rapidly penetrates to produce early and sustained drug levels in all ocular tissues. Clinically, these pharmacokinetic features are manifested in a rapid reduction of postsurgical inflammation and pain with bid dosing. Bromfenac ophthalmic solution 0.09% is a versatile agent and is effective when used as either monotherapy or as an adjunct therapy to steroids.