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Oydanich M, Roll EH, Uppuluri S, Khouri AS. Effectiveness of netarsudil 0.02% in lowering intraocular pressure in patients with secondary glaucoma. CANADIAN JOURNAL OF OPHTHALMOLOGY 2024; 59:247-252. [PMID: 37290487 DOI: 10.1016/j.jcjo.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 04/10/2023] [Accepted: 05/17/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To determine the effectiveness of netarsudil, 0.02% in lowering intraocular pressure (IOP) in patients with secondary forms of glaucoma. METHODS A total of 77 patients (98 eyes) with either primary open-angle glaucoma (POAG) or secondary glaucoma were reviewed retrospectively over the course of 1 year after starting netarsudil. The secondary glaucoma group was comprised of patients with uveitic, pseudoexfoliative, neovascular, congenital, and other forms of secondary glaucoma. Patient IOP measurements were collected at baseline and at 1-, 3-, 6-, and 12-month intervals. Two sample t tests and 1-way analysis of variance were used to determine differences in IOP reductions following netarsudil treatment. RESULTS Patients with POAG or secondary glaucomas were matched for age (mean ± SD: 69.1 ± 16.0 years vs. 64.5 ± 21.2 years; p = 0.30). Both the POAG and secondary glaucoma patients exhibited significant decreases in IOP at each time point (1, 3, 6, and 12 months) when compared with baseline (p < 0.05). Both groups showed similar overall decreases in IOP from baseline after 1 year of treatment (6.0 ± 4.5 mm Hg vs. 6.6 ± 8.4 mm Hg; p = 0.70). Forty-sex percent of POAG patients achieved an IOP of <14 mm Hg compared with 17% of secondary glaucoma patients. Among the secondary glaucoma subtypes, netarsudil was found to be most effective for treating uveitic glaucoma, showing a decrease in IOP of 9.5 mm Hg after 12 months (p = 0.02). CONCLUSION Netarsudil is effective in lowering IOP in patients with certain forms of secondary glaucoma and should be considered for IOP management in those with uveitic glaucoma.
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Affiliation(s)
- Marko Oydanich
- Institute of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, NJ
| | - Elizabeth H Roll
- Institute of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, NJ
| | - Siri Uppuluri
- Institute of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, NJ
| | - Albert S Khouri
- Institute of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, NJ.
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Liu LC, Chen YH, Lu DW. The Application of Rho Kinase Inhibitors in the Management of Glaucoma. Int J Mol Sci 2024; 25:5576. [PMID: 38891764 PMCID: PMC11171673 DOI: 10.3390/ijms25115576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/12/2024] [Accepted: 05/17/2024] [Indexed: 06/21/2024] Open
Abstract
Glaucoma is a chronic neurodegenerative disease that poses a significant threat of irreversible blindness worldwide. Current treatments for glaucoma focus on reducing intraocular pressure (IOP), which is the only modifiable risk factor. Traditional anti-glaucomatous agents, including carbonic anhydrase inhibitors, beta-blockers, alpha-2 agonists, and prostaglandin analogs, work by either improving uveoscleral outflow or reducing aqueous humor production. Rho kinase (ROCK) inhibitors represent a novel class of anti-glaucomatous drugs that have emerged from bench to bedside in the past decade, offering multifunctional characteristics. Unlike conventional medications, ROCK inhibitors directly target the trabecular meshwork outflow pathway. This review aims to discuss the mechanism of ROCK inhibitors in reducing IOP, providing neuroprotection, and preventing fibrosis. We also highlight recent studies and clinical trials evaluating the efficacy and safety of ROCK inhibitors, compare them with other clinical anti-glaucomatous medications, and outline future prospects for ROCK inhibitors in glaucoma treatment.
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Affiliation(s)
| | | | - Da-Wen Lu
- Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan; (L.-C.L.); (Y.-H.C.)
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Borrás T, Stepankoff M, Danias J. Genes as drugs for glaucoma: latest advances. Curr Opin Ophthalmol 2024; 35:131-137. [PMID: 38117663 DOI: 10.1097/icu.0000000000001025] [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: 12/22/2023]
Abstract
PURPOSE OF REVIEW To provide the latest advances on the future use of gene therapy for the treatment of glaucoma. RECENT FINDINGS In preclinical studies, a number of genes have been shown to be able to reduce elevated intraocular pressure (IOP), and to exert neuroprotection of the retinal ganglion cells. These genes target various mechanisms of action and include among others: MMP3 , PLAT, IκB, GLIS, SIRT, Tie-2, AQP1. Some of these as well as some previously identified genes ( MMP3, PLAT, BDNF, C3, TGFβ, MYOC, ANGPTL7 ) are starting to move onto drug development. At the same time, progress has been made in the methods to deliver and control gene therapeutics (advances in these areas are not covered in this review). SUMMARY While preclinical efforts continue in several laboratories, an increasing number of start-up and large pharmaceutical companies are working on developing gene therapeutics for glaucoma ( Sylentis, Quetera/Astellas, Exhaura, Ikarovec, Genentech, Regeneron, Isarna, Diorasis Therapeutics ). Despite the presence of generic medications to treat glaucoma, given the size of the potential world-wide market (∼$7B), it is likely that the number of companies developing glaucoma gene therapies will increase further in the near future.
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Affiliation(s)
- Teresa Borrás
- University of North Carolina at Chapel Hill, North Carolina
| | | | - John Danias
- Downstate Health Science University, SUNY, New York, USA
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Futterknecht S, Chatzimichail E, Gugleta K, Panos GD, Gatzioufas Z. The Role of Rho Kinase Inhibitors in Corneal Diseases. Drug Des Devel Ther 2024; 18:97-108. [PMID: 38264539 PMCID: PMC10804875 DOI: 10.2147/dddt.s435522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 01/10/2024] [Indexed: 01/25/2024] Open
Abstract
The cornea, as the outermost layer of the eye, plays a crucial role in vision by focusing light onto the retina. Various diseases and injuries can compromise its clarity, leading to impaired vision. This review aims to provide a thorough overview of the pharmacological properties, therapeutic potential and associated risks of Rho-associated protein kinase (ROCK) inhibitors in the management of corneal diseases. The article focuses on four key ROCK inhibitors: Y-27632, fasudil, ripasudil, and netarsudil, providing a comparative examination. Studies supporting the use of ROCK inhibitors highlight their efficacy across diverse corneal conditions. In Fuchs' endothelial corneal dystrophy, studies on the application of Y-27632, ripasudil, and netarsudil demonstrated noteworthy enhancements in corneal clarity, endothelial cell density, and visual acuity. In pseudophakic bullous keratopathy, the injection of Y-27632 together with cultured corneal endothelial cells into the anterior chamber lead to enhanced corneal endothelial cell density and improved visual acuity. Animal models simulating chemical injury to the cornea showed a reduction of neovascularization and epithelial defects after application of fasudil and in a case of iridocorneal endothelial syndrome netarsudil improved corneal edema. Addressing safety considerations, netarsudil and ripasudil, both clinically approved, exhibit adverse events such as conjunctival hyperemia, conjunctival hemorrhage, cornea verticillata, conjunctivitis, and blepharitis. Monitoring patients during treatment becomes crucial to balancing the potential therapeutic benefits with these associated risks. In conclusion, ROCK inhibitors, particularly netarsudil and ripasudil, offer promise in managing corneal diseases. The comparative analysis of their pharmacological properties and studies supporting their efficacy underscore their potential therapeutic significance. However, ongoing research is paramount to comprehensively understand their safety profiles and long-term outcomes in diverse corneal conditions, guiding their optimal application in clinical practice.
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Affiliation(s)
- Stefan Futterknecht
- Department of Ophthalmology, University Hospital of Basel, Basel, Switzerland
- Institute of Molecular and Clinical Ophthalmology Basel, Basel, Switzerland
| | | | - Konstantin Gugleta
- Department of Ophthalmology, University Hospital of Basel, Basel, Switzerland
- Department of Ophthalmology, School of Medicine, University of Basel, Basel, Switzerland
| | - Georgios D Panos
- Department of Ophthalmology, Queen’s Medical Centre, Nottingham University Hospitals, Nottingham, UK
- Division of Ophthalmology and Visual Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Zisis Gatzioufas
- Department of Ophthalmology, University Hospital of Basel, Basel, Switzerland
- Department of Ophthalmology, School of Medicine, University of Basel, Basel, Switzerland
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Stalmans I, Lim KS, Oddone F, Fichtl M, Belda JI, Hommer A, Laganovska G, Schweitzer C, Voykov B, Zarnowski T, Holló G. MERCURY-3: a randomized comparison of netarsudil/latanoprost and bimatoprost/timolol in open-angle glaucoma and ocular hypertension. Graefes Arch Clin Exp Ophthalmol 2024; 262:179-190. [PMID: 37615697 PMCID: PMC10806046 DOI: 10.1007/s00417-023-06192-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 06/22/2023] [Accepted: 07/23/2023] [Indexed: 08/25/2023] Open
Abstract
PURPOSE : To compare the efficacy and safety of the fixed-dose combination (FDC) of netarsudil 0.02%/latanoprost 0.005% ophthalmic solution (NET/LAT; Roclanda®) with bimatoprost 0.03%/timolol maleate 0.5% (BIM/TIM; Ganfort®) ophthalmic solution in the treatment of open-angle glaucoma (OAG) and ocular hypertension (OHT). METHODS MERCURY-3 was a 6-month prospective, double-masked, randomized, multicenter, active-controlled, parallel-group, non-inferiority study. Patients (≥ 18 years) with a diagnosis of OAG or OHT in both eyes that was insufficiently controlled with topical medication (IOP ≥ 17 mmHg in ≥ 1 eye and < 28 mmHg in both eyes) were included. Following washout, patients were randomized to once-daily NET/LAT or BIM/TIM for up to 6 months; efficacy was assessed at Week 2, Week 4, and Month 3; safety was evaluated for 6 months. Comparison of NET/LAT relative to BIM/TIM for mean IOP at 08:00, 10:00, and 16:00 h was assessed at Week 2, Week 6, and Month 3. Non-inferiority of NET/LAT to BIM/TIM was defined as a difference of ≤ 1.5 mmHg at all nine time points through Month 3 and ≤ 1.0 mmHg at five or more of nine time points through Month 3. RESULTS Overall, 430 patients were randomized (NET/LAT, n = 218; BIM/TIM, n = 212), and all received at least one dose of study medication. Efficacy analyses were performed at Month 3 on 388 patients (NET/LAT, n = 184; BIM/TIM, n = 204). NET/LAT demonstrated non-inferiority to BIM/TIM, with a between-treatment difference in IOP of ≤ 1.5 mmHg achieved at all time points and ≤ 1.0 mmHg at the majority of time points (six of nine) through Month 3. Mean diurnal IOP during the study ranged from 15.4 to 15.6 mmHg and 15.2 to 15.6 mmHg in the NET/LAT and BIM/TIM groups respectively, with no between-group statistically significant difference. No significant differences were observed in key secondary endpoints. No serious, treatment-related adverse events (AEs) were observed, and AEs were typically mild/moderate in severity. The most common treatment-related AEs were conjunctival hyperemia (NET/LAT, 30.7%; BIM/TIM, 9.0%) and cornea verticillata (NET/LAT, 11.0%; BIM/TIM, 0%). CONCLUSIONS Once-daily NET/LAT was non-inferior to BIM/TIM in IOP reduction in OAG and OHT, with AEs consistent with previous findings. NET/LAT offers a compelling alternative FDC treatment option for OAG and OHT.
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Affiliation(s)
- Ingeborg Stalmans
- Department of Ophthalmology, University Hospitals UZ Leuven, Louvain, Belgium.
- Research Group of Ophthalmology, Department of Neurosciences, Catholic University KU Leuven, Louvain, Belgium.
| | - Kin Sheng Lim
- KCL Frost Eye Research Department, St Thomas' Hospital, London, UK
| | | | - Marek Fichtl
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
- Department of Ophthalmology for Children and Adults, Second Faculty of Medicine, Charles University and University Hospital Motol in Prague, Prague, Czech Republic
| | - Jose I Belda
- Department of Ophthalmology, Hospital Universitario de Torrevieja, Alicante, Spain
- Visionker Eye Clinic, Torrevieja, Spain
| | - Anton Hommer
- Private Office for Ophthalmology and Optometry, Albertgasse 39/10, 1080, Vienna, Austria
| | - Guna Laganovska
- Riga Stradins University, P.Stradins Clinical University Hospital, Riga, Latvia
| | - Cédric Schweitzer
- CHU Bordeaux, Department of Ophthalmology, 33000, Bordeaux, France
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Team LEHA, UMR 1219, 33000, Bordeaux, France
| | - Bogomil Voykov
- Centre for Ophthalmology, University Hospital Tuebingen, Tuebingen, Germany
| | - Tomasz Zarnowski
- Department of Diagnostics and Microsurgery of Glaucoma, Medical University, Lublin, Poland
| | - Gábor Holló
- Tutkimusz Ltd, Solymár, Hungary
- Eye Center, Prima Medica Health Centers, Budapest, Hungary
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Wang J, Wang H, Dang Y. Rho-Kinase Inhibitors as Emerging Targets for Glaucoma Therapy. Ophthalmol Ther 2023; 12:2943-2957. [PMID: 37837578 PMCID: PMC10640453 DOI: 10.1007/s40123-023-00820-y] [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: 07/30/2023] [Accepted: 09/13/2023] [Indexed: 10/16/2023] Open
Abstract
Glaucoma, the leading cause of irreversible blindness worldwide, is a chronic and progressive optic neuropathy characterized by damage to the optic and retinal nerve fiber layers, which can lead to permanent loss of peripheral or central vision. Reduction of intraocular pressure (IOP) is the only known modifiable risk factor for preventing and treating glaucoma. Rho kinase (ROCK) inhibitors are a new class of glaucoma drugs with a novel mechanism of action and good safety profile. They exert neuroprotective effects, act on the trabecular tissue, increase the outflow of aqueous humor, and reduce intraocular pressure. However, they also cause local adverse reactions, including common conjunctival congestion and subconjunctival bleeding; however, most are self-limiting and temporary. Netarsudil (0.02%), a ROCK inhibitor, relaxes the trabecular meshwork, increases the outflow of aqueous humor, reduces scleral venous pressure, and directly decreases IOP. Conjunctival congestion can be reduced if netarsudil is administered at night. The combination of these medications is always more effective than the single drug. Ripasudil (0.4%), another ROCK inhibitor, also lowers IOP; however, conjunctival hyperemia is the most common adverse drug reaction. The purpose of this review is to summarize the effects and adverse reactions of ROCK inhibitors in the experimental trial stage and in clinical treatment in recent years, providing suggestions for future clinical drug use, and research and development to reduce the side effects of these drugs, maximize the potential for reducing IOP, and improve the therapeutic effect.
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Affiliation(s)
- Jun Wang
- School of Basic Medical Sciences, Henan University, Kaifeng, China
- Henan International Joint Laboratory for Nuclear Protein Regulation, Henan University, Kaifeng, China
| | - Hanke Wang
- School of Basic Medical Sciences, Henan University, Kaifeng, China
- Henan International Joint Laboratory for Nuclear Protein Regulation, Henan University, Kaifeng, China
| | - Yalong Dang
- Henan International Joint Laboratory for Nuclear Protein Regulation, Henan University, Kaifeng, China.
- Henan International Joint Laboratory for Outflow Engineering, Sanmenxia Central Hospital, Sanmenxia, China.
- Department of Ophthalmology, Sanmenxia Central Hospital, Henan University of Science and Technology, Sanmenxia, 472000, China.
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Pagano L, Lee JW, Posarelli M, Giannaccare G, Kaye S, Borgia A. ROCK Inhibitors in Corneal Diseases and Glaucoma-A Comprehensive Review of These Emerging Drugs. J Clin Med 2023; 12:6736. [PMID: 37959203 PMCID: PMC10648286 DOI: 10.3390/jcm12216736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/17/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
Rho kinase (ROCK) inhibitors have gained significant attention as emerging novel treatment options in the field of ophthalmology in recent years. The evidence supporting their efficacy in glaucoma and corneal pathology includes both in vitro and clinical studies. Among the available options, ripasudil and netarsudil have emerged as the leading ROCK inhibitors, and some countries have approved these therapeutic options as treatments for glaucoma. Various dosing regimens have been studied, including monotherapy and combination therapy, especially for patients with secondary glaucoma who are already on multiple medications. Another rising application of ROCK inhibitors includes their use as an adjunct in surgical procedures such as Descemetorhexis Without Endothelial Keratoplasty (DWEK), Descemet Stripping Only (DSO) to accelerate visual recovery, glaucoma surgeries to reduce scarring process and allow better intraocular pressure (IOP) control, or after complicated anterior segment surgery to treat corneal oedema. This article provides a comprehensive overview of the existing literature in the field, offering recommendations for prescribing ROCK inhibitors and also discussing patient selection, drug efficacy, and possible adverse effects.
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Affiliation(s)
- Luca Pagano
- Department of Biomedical Sciences, Humanitas University, 20072 Milano, Italy;
| | - Jason William Lee
- Clinical Eye Research Centre, St Paul’s Eye Unit, Royal Liverpool University Hospital, Liverpool L7 8YE, UK;
| | - Matteo Posarelli
- Department of Corneal Diseases, St. Paul’s Eye Unit, Royal Liverpool University Hospital, Liverpool L7 8YE, UK; (M.P.); (S.K.); (A.B.)
- Ophthalmology Unit of the Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Giuseppe Giannaccare
- Eye Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy
| | - Stephen Kaye
- Department of Corneal Diseases, St. Paul’s Eye Unit, Royal Liverpool University Hospital, Liverpool L7 8YE, UK; (M.P.); (S.K.); (A.B.)
| | - Alfredo Borgia
- Department of Corneal Diseases, St. Paul’s Eye Unit, Royal Liverpool University Hospital, Liverpool L7 8YE, UK; (M.P.); (S.K.); (A.B.)
- Eye Unit, Humanitas-Gradenigo Hospital, 10122 Turin, Italy
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Araie M, Sugiyama K, Aso K, Kanemoto K, Iwata R, Hollander DA, Senchyna M, Kopczynski CC. Phase 3 Clinical Trial Comparing the Safety and Efficacy of Netarsudil to Ripasudil in Patients with Primary Open-Angle Glaucoma or Ocular Hypertension: Japan Rho Kinase Elevated Intraocular Pressure Treatment Trial (J-ROCKET). Adv Ther 2023; 40:4639-4656. [PMID: 37603205 PMCID: PMC10499948 DOI: 10.1007/s12325-023-02550-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/11/2023] [Indexed: 08/22/2023]
Abstract
INTRODUCTION A clinical trial evaluated ocular hypotensive efficacy and safety of netarsudil 0.02% once daily (QD) relative to ripasudil 0.4% twice daily (BID). METHODS This was a single-masked, randomized, phase 3, superiority study. Japanese patients were randomized to either the netarsudil 0.02% group or the ripasudil 0.4% group in a 1:1 ratio and treated for 4 weeks. The primary efficacy variable was mean diurnal intraocular pressure (IOP) (average of diurnal time points at 09:00, 11:00, and 16:00) at Week 4. RESULTS A total of 245 patients were included in the primary analysis. At Week 4, least squares (LS) mean of diurnal IOP adjusted for baseline was 15.96 and 17.71 mmHg in the netarsudil 0.02% and ripasudil 0.4% groups, respectively, demonstrating the superiority of netarsudil 0.02% QD over ripasudil 0.4% BID by a margin of - 1.74 mmHg (p < 0.0001). Mean reduction from baseline in mean diurnal IOP at Week 4 was 4.65 and 2.98 mmHg, respectively. Adverse events (AEs) occurred less frequently in netarsudil 0.02% than in ripasudil 0.4%, with the incidence of ocular AEs being 59.8% and 66.7%, respectively. The most frequently reported AE was conjunctival hyperemia in both groups, with an incidence of 54.9% and 62.6%, respectively. No serious eye-related AEs were reported. CONCLUSION Netarsudil ophthalmic solution 0.02% dosed QD (p.m.) was well tolerated and more effective in reducing IOP than ripasudil ophthalmic solution 0.4% dosed BID. Netarsudil 0.02% QD may become an important option for the treatment of Japanese patients with primary open-angle glaucoma (POAG) or ocular hypertension (OHT). TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT04620135.
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Affiliation(s)
- Makoto Araie
- Sekikawa Hospital, 1-4-1, Nishinippori, Arakawa-ku, Tokyo, Japan.
| | - Kazuhisa Sugiyama
- Department of Ophthalmology, Kanazawa University Graduate School of Medical Science, Ishikawa, Japan
| | - Kenji Aso
- Aerie Pharmaceuticals, Ireland Ltd., Japan Branch, Tokyo, Japan
| | - Koji Kanemoto
- Aerie Pharmaceuticals, Ireland Ltd., Japan Branch, Tokyo, Japan
| | - Ryo Iwata
- Aerie Pharmaceuticals, Ireland Ltd., Japan Branch, Tokyo, Japan
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Mahalingam K, Joshi S, Vanathi M, Gupta V, Gupta S. Honeycomb ensemble of corneal epithelium. Clin Exp Optom 2023; 106:681-682. [PMID: 35358394 DOI: 10.1080/08164622.2022.2058870] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/05/2022] [Accepted: 03/23/2022] [Indexed: 10/18/2022] Open
Affiliation(s)
- Karthikeyan Mahalingam
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Shivani Joshi
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Murugesan Vanathi
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Viney Gupta
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Shikha Gupta
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
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Ruiz-Lozano RE, Azar NS, Mousa HM, Quiroga-Garza ME, Komai S, Wheelock-Gutierrez L, Cartes C, Perez VL. Ocular surface disease: a known yet overlooked side effect of topical glaucoma therapy. FRONTIERS IN TOXICOLOGY 2023; 5:1067942. [PMID: 37547228 PMCID: PMC10403269 DOI: 10.3389/ftox.2023.1067942] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 07/14/2023] [Indexed: 08/08/2023] Open
Abstract
Ocular surface disease (OSD), a disorder affecting the lacrimal and meibomian glands and the corneal and conjunctival epithelium, is a well-known complication of topical glaucoma therapy. OSD can present as a new or pre-existing condition that virtually any anti-glaucoma formulation can exacerbate. As such, both glaucoma and OSD frequently coexist. Typical OSD symptoms include ocular discomfort, redness, burning, and dryness, whereas signs include periorbital and eyelid skin pigmentation, conjunctival scarring, and superficial punctate keratitis. Pressure-lowering eyedrops can cause toxic, allergic, and inflammatory reactions on the ocular surface. The latter can result from either preservatives or direct toxicity from the active molecule. Although usually mild, OSD can cause significant symptoms that lead to poor quality of life, decreased compliance to therapy, glaucoma progression, and worse visual outcomes. Given the chronic nature of glaucoma, lack of curative therapy, and subsequent lifelong treatment, addressing OSD is necessary. This manuscript aims to provide an up-to-date overview of OSD's signs, symptoms, and pathogenic mechanisms from glaucoma therapy toxicity.
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Affiliation(s)
- Raul E. Ruiz-Lozano
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de La Salud, Monterrey, Mexico
| | - Nadim S. Azar
- Department of Ophthalmology, Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, NC, United States
| | - Hazem M. Mousa
- Department of Ophthalmology, Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, NC, United States
| | - Manuel E. Quiroga-Garza
- Department of Ophthalmology, Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, NC, United States
| | - Seitaro Komai
- Department of Ophthalmology, Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, NC, United States
| | | | - Cristian Cartes
- Unidad Oftalmología, Departamento de Especialidades, Facultad de Medicina, Universidad de La Frontera, Temuco, Chile
| | - Victor L. Perez
- Department of Ophthalmology, Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, NC, United States
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Mathur MC, Ratnam PV, Saikumar S, John M, Ravishankar S, Dinesh M, Chandil P, Pahuja K, Cherlikar V, Wadhwani S, Bendale P, Hazari A, Mishra R, Deshmukh S, Achlerkar RR, Shah DT, Hingorani C, Shah K, Topiwala P, Jani S, Rana VG, Majumdar NK, Chakrabarti D, Dey R, Halder D, Choudhury S, Kumar A, Das S, Nanda AK, Kumar VB, Dubey R, Kamdar GA, Pandey A, Kishanpuria S, Srivastava RM, Singh P, Verma SK, Sharma N, Gupta R. Netarsudil monotherapy as the initial treatment for open-angle glaucoma and ocular hypertension in Indian patients: A real-world evaluation of efficacy and safety. Indian J Ophthalmol 2023; 71:2500-2503. [PMID: 37322670 PMCID: PMC10418014 DOI: 10.4103/ijo.ijo_25_23] [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: 01/03/2023] [Revised: 03/13/2023] [Accepted: 03/21/2023] [Indexed: 06/17/2023] Open
Abstract
Purpose Glaucoma is the second leading cause of blindness worldwide, affecting more than 64 million people aged 40-80. The best way to manage primary open-angle glaucoma (POAG) is by lowering the intraocular pressure (IOP). Netarsudil is a Rho kinase inhibitor, the only class of antiglaucoma medications that reorganizes the extracellular matrix to improve the aqueous outflow through the trabecular pathway. Methods An open-label, real-world, multicentric, observation-based 3-month study was performed for assessing the safety and ocular hypotensive efficacy of netarsudil ophthalmic solution (0.02% w/v) in patients with elevated IOP. Patients were given netarsudil ophthalmic solution (0.02% w/v) as a first-line therapy. Diurnal IOP measurements, best-corrected visual acuity, and adverse event assessments were recorded at each of the five visits (Day-1: screening day and first dosing day; subsequent observations were taken at 2 weeks, 4 weeks, 6 weeks, and 3 months). Results Four hundred and sixty-nine patients from 39 centers throughout India completed the study. The mean IOP at baseline of the affected eyes was 24.84 ± 6.39 mmHg (mean ± standard deviation). After the first dose, the IOP was measured after 2, 4, and 6 weeks, with the final measurement taken at 3 months. The percentage reduction in IOP in glaucoma patients after 3 months of once-daily netarsudil 0.02% w/v solution use was 33.34%. The adverse effects experienced by patients were not severe in the majority of cases. Some adverse effects observed were redness, irritation, itching, and others, but only a small number of patients experienced severe reactions, as reported in a decreasing order: redness > irritation > watering > itching > stinging > blurring. Conclusion We found that netarsudil 0.02% w/v solution monotherapy when used as the first-line treatment in primary open-angle glaucoma and ocular hypertension was both safe and effective.
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Affiliation(s)
| | | | | | - Manuel John
- Holy Ghost Mission Hospital, Kottayam, Kerala, India
| | | | - M.B Dinesh
- Uma Eye Clinic, Chennai, Tamil Nadu, India
| | | | - Kishore Pahuja
- Natasha Eye Care and Research Centre, Pune, Maharashtra, India
| | | | | | - Pankaj Bendale
- Dr. Bendale’s Eye Care, Pimpri-Chinchwad, Maharashtra, India
| | - Ajit Hazari
- Hazari Nursing Home, Aurangabad, Maharashtra, India
| | - Rajesh Mishra
- Advanced Eye Hospital, A Unit of Dr Agarwals Eye Hospital, Vashi, Navi Mumbai, Maharashtra, India
| | - Susheel Deshmukh
- Sudrishti Eye Care and Goregaon Glaucoma Centre, Mumbai, Maharashtra, India
| | | | | | | | - Kaivan Shah
- Bhavna Super Speciality Eye Care, Surat, Gujarat, India
| | | | - Sheetal Jani
- Netralaya Superspecialty Eye Hospital, Ahmedabad, Gujarat, India
| | - Viral G. Rana
- Shree Bidada Survoday Trust- Laxmi Jyot Eye Hospital, Bidada, Gujarat, India
| | | | | | - Rituparna Dey
- Citizen’s Eye and Healthcare, Hooghly, West Bengal, India
| | | | | | - Ajeet Kumar
- Sharda Eye and Dental Hospital, Patna, Bihar, India
| | - Sasmita Das
- Kar Vision Eye Hospital, Bhubaneshwar, Odisha, India
| | | | | | - Rama Dubey
- Rama Eye Hospital, Jaipur, Rajasthan, India
| | | | | | | | | | - Parul Singh
- GSVM Medical College, Kanpur,Uttar Pradesh, India
| | | | - Neha Sharma
- P.C. Sharma Eye Hospital, Ambala, Haryana, India
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12
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Sharif NA. Recently Approved Drugs for Lowering and Controlling Intraocular Pressure to Reduce Vision Loss in Ocular Hypertensive and Glaucoma Patients. Pharmaceuticals (Basel) 2023; 16:791. [PMID: 37375739 DOI: 10.3390/ph16060791] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 05/17/2023] [Accepted: 05/19/2023] [Indexed: 06/29/2023] Open
Abstract
Serious vision loss occurs in patients affected by chronically raised intraocular pressure (IOP), a characteristic of many forms of glaucoma where damage to the optic nerve components causes progressive degeneration of retinal and brain neurons involved in visual perception. While many risk factors abound and have been validated for this glaucomatous optic neuropathy (GON), the major one is ocular hypertension (OHT), which results from the accumulation of excess aqueous humor (AQH) fluid in the anterior chamber of the eye. Millions around the world suffer from this asymptomatic and progressive degenerative eye disease. Since clinical evidence has revealed a strong correlation between the reduction in elevated IOP/OHT and GON progression, many drugs, devices, and surgical techniques have been developed to lower and control IOP. The constant quest for new pharmaceuticals and other modalities with superior therapeutic indices has recently yielded health authority-approved novel drugs with unique pharmacological signatures and mechanism(s) of action and AQH drainage microdevices for effectively and durably treating OHT. A unique nitric oxide-donating conjugate of latanoprost, an FP-receptor prostaglandin (PG; latanoprostene bunod), new rho kinase inhibitors (ripasudil; netarsudil), a novel non-PG EP2-receptor-selective agonist (omidenepag isopropyl), and a form of FP-receptor PG in a slow-release intracameral implant (Durysta) represent the additions to the pharmaceutical toolchest to mitigate the ravages of OHT. Despite these advances, early diagnosis of OHT and glaucoma still lags behind and would benefit from further concerted effort and attention.
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Affiliation(s)
- Najam A Sharif
- Eye-APC Duke-NUS Medical School, Singapore 169856, Singapore
- Singapore Eye Research Institute, Singapore 169856, Singapore
- Department of Pharmacology and Neuroscience, University of North Texas Health Sciences Center, Fort Worth, TX 76107, USA
- Department of Pharmacy Sciences, Creighton University, Omaha, NE 68178, USA
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX 77004, USA
- Imperial College of Science and Technology, St. Mary's Campus, London SW7 2BX, UK
- Institute of Ophthalmology, University College London, London WC1E 6BT, UK
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13
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Karri R, Chong EW. ROCK inhibitors in ophthalmology: A critical review of the existing clinical evidence. Clin Exp Ophthalmol 2023. [PMID: 37037790 DOI: 10.1111/ceo.14224] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 03/12/2023] [Accepted: 03/24/2023] [Indexed: 04/12/2023]
Abstract
Rho kinase (ROCK) inhibitors have emerged as a key therapeutic class of interest in ophthalmology over the last decade. Promising in vitro studies laid the foundations for the development of novel therapeutic agents that target the ROCK signalling pathway in ocular disease, with subsequent clinical trials supporting their use. Corneal endothelial disease, glaucoma, and vitreoretinal disease are the major pathologies in which ROCK inhibitors have been investigated to date. Ripasudil and netarsudil represent the current leaders in this pharmaceutical group, having been extensively validated and approved for use in glaucoma in some countries. Less substantial evidence exists for fasudil in ophthalmic use. ROCK inhibitors are also increasingly used in cultured endothelial cell grafting and as an adjunct to aid in endothelial cell migration and replication in Descemet's stripping procedures or Descemet's membrane injuries. This review has synthesised both established and emerging research to provide a practical guide to prescribing in this drug class. Drug efficacies, side effect profiles, and the demographic and clinical characteristics of appropriate drug candidates are discussed.
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Affiliation(s)
- Roshan Karri
- Department of Ophthalmology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Centre for Eye Research Australia, Melbourne, Victoria, Australia
| | - Elaine W Chong
- Department of Ophthalmology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Centre for Eye Research Australia, Melbourne, Victoria, Australia
- Royal Victorian Eye & Ear Hospital, Melbourne, Victoria, Australia
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14
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Sun X, Yao K, Liu Q, Zhang H, Xing X, Fang A, Duan X, Yu M, Chen MY, Yang J, Goodkin ML. Safety of Fixed-Combination Bimatoprost 0.03%/Timolol 0.5% Ophthalmic Solution at 6 Months in Chinese Patients with Open-Angle Glaucoma or Ocular Hypertension. Ophthalmol Ther 2023; 12:341-353. [PMID: 36370233 PMCID: PMC9834455 DOI: 10.1007/s40123-022-00593-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/06/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Fixed-combination bimatoprost 0.03%/timolol 0.5% ophthalmic solution (FCBT; Ganfort®, Allergan, an AbbVie company) effectively reduces intraocular pressure (IOP) via complementary mechanisms of action of the agents, but long-term (> 12 weeks) safety evaluations of FCBT remain limited. FCBT safety is evaluated herein, with particular focus on hyperemia and eyelash growth, at 24 weeks in Chinese patients with open-angle glaucoma (OAG) or ocular hypertension (OHT). METHODS In this multicenter, open-label, noncomparative, phase 4 study conducted in China, patients diagnosed with OAG or OHT having insufficient response to β-blocker- or prostaglandin analogue/prostamide (PGA)-based IOP-lowering monotherapy in one or both eyes were switched from their current IOP-lowering treatment to FCBT (one drop per eye every evening) without prior washout. Assessment visits were scheduled at baseline and weeks 4, 12, and 24 (or study exit). The primary outcome measure was adverse event (AE) incidence through 24 weeks. RESULTS Of 725 patients enrolled, 632 (87.2%) completed the study; 93 (12.8%) patients discontinued, including 29 (4.0%) due to AEs. Of 1326 FCBT-treated eyes (total), 594 (44.8%) experienced ≥ 1 ocular treatment-related AE during the study. Conjunctival hyperemia (the most common AE overall) and eyelash growth were reported in 269 (20.3%) and 54 (4.1%) FCBT-treated eyes, respectively. The incidence of other known PGA-related AEs (including blepharal pigmentation and erythema of eyelid) was < 10% each. Most conjunctival hyperemia reports were mild in severity (214/259; 82.6%) and only 1/259 (0.4%) was severe. Similarly, most cases of eyelash growth were mild (46/52; 88.5%); none were severe. One (< 0.1%) FCBT-treated eye had a serious ocular AE (OAG) considered FCBT-related. CONCLUSIONS The frequency and severity of FCBT-related AEs, including conjunctival hyperemia and eyelash growth, are consistent with previously published findings. No new safety concerns were raised. This prospective study reaffirms that once-daily FCBT is a safe and well-tolerated therapy for OAG and OHT. CLINICALTRIALS GOV IDENTIFIER NCT02571712.
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Affiliation(s)
- Xinghuai Sun
- Eye & ENT Hospital of Fudan University, No. 83, Fenyang Road, Xuhui District, Shanghai, China.
| | - Ke Yao
- Eye Center of the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | | | - Hong Zhang
- Tongji Hospital of Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
| | - Xiaoli Xing
- Tianjin Medical University Eye Hospital, Tianjin, China
| | - Aiwu Fang
- Eye Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xuanchu Duan
- Second Xiangya Hospital of Central South University, Changsha, China
| | - Minbin Yu
- Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Michelle Y Chen
- Allergan (an AbbVie Company), Irvine, CA, USA
- Perfuse Therapeutics, Inc., San Francisco, CA, USA
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15
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Ramesh P, Parthasarathi S, Sathyan P, Ray P. Netarsudil-associated reversible “honeycomb” pattern corneal epithelial edema. JOURNAL OF CLINICAL OPHTHALMOLOGY AND RESEARCH 2023. [DOI: 10.4103/jcor.jcor_12_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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16
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Menon MG, Goodkin ML. Triple Fixed-Combination Bimatoprost/Brimonidine/Timolol in Glaucoma and Ocular Hypertension in India: A Multicenter, Open-Label, Phase 3 Study. Clin Ophthalmol 2022; 16:3559-3569. [PMID: 36274674 PMCID: PMC9582300 DOI: 10.2147/opth.s369626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction To evaluate the intraocular pressure (IOP)-lowering efficacy and safety of a triple fixed-combination of bimatoprost, brimonidine, and timolol (TFC) in patients with glaucoma or ocular hypertension (OHT) treated with fixed-combination or unfixed brimonidine and timolol therapy (dual-combination therapy). Methods In this multicenter, open-label, phase 3 study, patients who received 4-8 weeks of dual-combination therapy twice daily and had an IOP >18 and <34 mmHg in at least one eye were switched (at baseline) to treatment with TFC twice daily for 12 weeks. At Weeks 4, 8, and 12 on TFC, IOP was assessed at Hours 0, 2, and 8. Primary efficacy variable: mean diurnal IOP change from baseline in the study eye at Week 12 (modified intent-to-treat [mITT] population). Sensitivity (per-protocol [PP] population) and subgroup (≤65 vs >65 years) analyses were performed. Safety, including adverse events (AEs), was assessed at each visit. Results Of 126 patients enrolled, 121 and 103 formed the mITT/safety and PP populations, including 109 (90.1%) and 94 (91.3%) who completed the study, respectively. In the mITT/safety population, mean age was 58.6 years. Patients had open-angle glaucoma (51.2%), angle-closure glaucoma with patent iridotomy (36.4%), and/or OHT (13.2%). At Week 12, the mean diurnal change in IOP from dual combination-treated baseline was statistically significant (P<0.001) with TFC in the mITT (-3.98 mmHg) and PP (-4.22 mmHg) populations. Results were similar at all visits, regardless of the age subgroup. The most frequent treatment-related AEs were conjunctival hyperemia (14.0%) and dry eye (4.1%); 5.8% of the patients discontinued treatment due to ocular AEs. Conclusion TFC offers a beneficial therapeutic alternative for patients with glaucoma or OHT whose IOP is not sufficiently controlled with dual-combination therapy. Safety and efficacy findings support those of published studies of TFC in primary open-angle glaucoma and OHT, despite differences in study designs.
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Affiliation(s)
- Meena G Menon
- Glaucoma Services, Sankara Eye Hospital, Bangalore, Karnataka, India,Correspondence: Meena G Menon, Glaucoma Services, Sankara Eye Hospital, Bangalore, Karnataka, India, Email
| | - Margot L Goodkin
- Ophthalmology Clinical Development, Allergan (an AbbVie Company), Irvine, CA, USA
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17
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Kaplan TM, Sit AJ. Emerging drugs for the treatment of glaucoma: a review of phase II & III trials. Expert Opin Emerg Drugs 2022; 27:321-331. [PMID: 35924872 DOI: 10.1080/14728214.2022.2110240] [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] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Glaucoma is a progressive optic neuropathy and the leading cause of irreversible vision loss. By 2040, the number of individuals with glaucoma is expected to nearly double. The only known modifiable risk factor for glaucoma is intraocular pressure. Topical medications are often used as first-line therapies. Although there are numerous available treatments, there continues to be a need for the development of new medical therapies due to variable response, intolerable side-effect profiles in some patients, and elevated intraocular pressure refractory to other treatments. AREAS COVERED This review will cover glaucoma medications currently undergoing phase II and III of drug development. EXPERT OPINION There are numerous drugs currently in development that have demonstrated significant and clinically relevant reduction of intraocular pressure. Differentiating factors include improved tolerability, novel mechanisms of action, multiple mechanisms of action, or superior IOP reduction. However, the availability of generic prostaglandin analogs may limit adoption of these novel compounds as first-line agents, except for certain subgroups of glaucoma patients. Use as adjuvant or second-line therapy appears more likely for the majority of glaucoma patients.
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Affiliation(s)
- Tyler M Kaplan
- Department of Ophthalmology, Mayo Clinic, Rochester, MN, USA
| | - Arthur J Sit
- Department of Ophthalmology, Mayo Clinic, Rochester, MN, USA
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18
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Goergen NS, Gagrani M, Gulati V, Ghate D. Pragmatic adjunctive usage of netarsudil: A retrospective chart review from a tertiary care center. Indian J Ophthalmol 2022; 70:2906-2910. [PMID: 35918941 DOI: 10.4103/ijo.ijo_2947_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Purpose This retrospective chart review of netarsudil (Rhopressa) characterizes intra-ocular pressure (IOP) reduction, drug tolerance, drug cost, and compliance in a tertiary university Midwest clinic in a variety of glaucoma diagnoses on patients prescribed netarsudil 01/2017 to 5/2020. Methods Patient demographics, primary diagnosis, indication for medication, prescription date, prescription fill status, duration of use, discontinuation reason, and number of IOP-lowering medications were noted. Confounding medication changes were excluded from IOP analysis. The IOP difference between the first visit after starting netarsudil and the baseline (mean before starting netarsudil on the stable medication regimen) was calculated. Results A total of 133 patients were prescribed netarsudil (age 69 ± 20 years, 59% females, 79% white, 86% primary glaucoma) as adjunct glaucoma medication (mean medications 3.2 ± 0.9). Indications were lowering IOP (mean baseline IOP 20.0 ± 6 mmHg) and drug regimen simplification. Prescription was not filled by 22/133 subjects because of the cost (68%) and the need for surgery (23%). No demographic factors were associated with prescription fill status. A total of 101 eyes of 76 patients were used for IOP analysis. The mean change in IOP was -0.8 ± 6.4 mmHg, (IOP decrease in 67%, increase or no change in 33% eyes). Netarsudil was discontinued in 52% (50/96) patients; the reasons include surgery for IOP control (42%), allergies (30%), cost (14%), and paradoxical rise in IOP (12%). Conclusion Netarsudil was used as adjunct third or fourth line medication at a glaucoma practice in Midwestern USA. 17% of prescriptions went unfilled; netarsudil was discontinued in 52% of patients. IOP response was variable in this population with severe complex glaucoma.
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Affiliation(s)
- Nate S Goergen
- Department of Ophthalmology and Visual Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Meghal Gagrani
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Vikas Gulati
- Department of Ophthalmology and Visual Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Deepta Ghate
- Department of Ophthalmology, Emory School of Medicine, Atlanta, GA, USA
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Jeang LJ, Shah AS, Hammer JD, Tuli SS. Reticular epithelial edema after penetrating keratoplasty in a patient taking netarsudil. Digit J Ophthalmol 2022; 28:34-37. [PMID: 35854963 PMCID: PMC9255647 DOI: 10.5693/djo.02.2022.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Netarsudil is a relatively new medication for the treatment of primary open-angle glaucoma and ocular hypertension. It has been associated with red eyes and burning after instillation. Reticular epitheliopathy is a relatively rare complication of netarsudil that has been described in patients with preexisting corneal edema. We report the case of a healthy 76-year-old woman who developed reticular epitheliopathy after full-thickness penetrating keratoplasty that completely resolved following discontinuation of the medication. In cases where netarsudil is initiated for treatment of glaucoma or, off-label, endothelial dysfunction, reticular epithelial edema should be considered in patients complaining of a decline in vision and severe pain.
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Affiliation(s)
| | | | | | - Sonal S. Tuli
- Cornea, External Disease and Refractive Surgery, Department of Ophthalmology, University of Florida, College of Medicine, Gainesville, Florida
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20
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Bhargava M, Sen S, Bhambhani V, Paul RS, Dutta C. Reticular epithelial corneal edema as a novel side-effect of Rho Kinase Inhibitors: An Indian scenario. Indian J Ophthalmol 2022; 70:1163-1170. [PMID: 35326007 PMCID: PMC9240559 DOI: 10.4103/ijo.ijo_2865_21] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Purpose To describe clinical course, characteristics, and outcome of reticular epithelial corneal edema (RECE) occurring as a not-so-infrequent adverse effect of a novel drug, Rho-kinase inhibitors (ROCK-I)- netarsudil (0.02%) and ripasudil (0.4%). Methods This was a retrospective observational non-randomized study. In this study, 12 eyes of 11 patients presenting at a tertiary eye care center between April 2021 and September 2021 were included. All 12 eyes developed a distinctive honeycomb pattern of RECE after starting topical ROCK-I. All patients were subjected to detailed ophthalmic examinations. Results Eight patients were started on netarsudil (0.02%) and three on ripasudil (0.4%). Five eyes had a prior history of corneal edema. The remaining seven had the presence of ocular comorbidities predisposing to corneal edema. The average time for RECE occurrence was 25 days for netarsudil and 82 days for ripasudil. Visual acuity decreased in two eyes, remained unaffected in four eyes, and could not be quantified in four eyes due to preexisting profound visual impairment. Five eyes had symptoms of ocular surface discomfort associated with bullae. Symptoms and bullae resolved in all eyes in whom ROCK-I was stopped. The average time to resolution of RECE was 10 days for netarsudil and 25 days for ripasudil. Conclusion RECE after ROCK-I occurs with the use of both netarsudil and ripasudil, although the characteristics differ. The presence of corneal edema and endothelial decompensation seem to be a risk factor, and cautious use is warranted in these patients. Four clinical stages of RECE are described. ROCK-I act as a double-edged sword in patients with endothelial decompensation. Large-scale studies are required to know the exact incidence, pathophysiology, and long-term consequences of the aforementioned side-effect.
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Affiliation(s)
- Mona Bhargava
- Department of Cornea and Ocular Surface, Aditya Birla Sankara Nethralaya, Kolkata, West Bengal (A Unit of Medical Research Foundation, Chennai), India
| | - Surajit Sen
- Department of Glaucoma, Aditya Birla Sankara Nethralaya, Kolkata, West Bengal (A Unit of Medical Research Foundation, Chennai), India
| | - Varsha Bhambhani
- Department of Cornea and Ocular Surface, Aditya Birla Sankara Nethralaya, Kolkata, West Bengal (A Unit of Medical Research Foundation, Chennai), India
| | - Raj Shekhar Paul
- Department of Cornea and Ocular Surface, Aditya Birla Sankara Nethralaya, Kolkata, West Bengal (A Unit of Medical Research Foundation, Chennai), India
| | - Chandana Dutta
- Department of Glaucoma, Aditya Birla Sankara Nethralaya, Kolkata, West Bengal (A Unit of Medical Research Foundation, Chennai), India
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Wu JH, Chang SN, Nishida T, Kuo BI, Lin JW. Intraocular pressure-lowering efficacy and ocular safety of Rho-kinase inhibitor in glaucoma: a meta-analysis and systematic review of prospective randomized trials. Graefes Arch Clin Exp Ophthalmol 2022; 260:937-948. [PMID: 34491427 DOI: 10.1007/s00417-021-05379-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/05/2021] [Accepted: 08/10/2021] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To evaluate the intraocular pressure (IOP)-reducing efficacy and safety of Rho-kinase inhibitor (RKI). METHODS Published studies in PubMed and EMBASE were searched on March 20, 2021. Study selection and data extraction were performed according to PRISMA. Meta-analysis of the IOP-lowering effect was performed with the bivariate random-effects model, with studies categorized into 2 classes: RKI versus placebo and RKI versus another medication. The main outcome was the difference in IOP reduction between RKI and non-RKI groups. Subgroup analysis of adjunctive RKI efficacy and additional review of its major ocular adverse events (AE) were also performed. RESULTS Ten (2.6%) out of 391 studies were retrieved. In the RKI versus placebo class, RKI showed greater IOP reduction after 4-8 weeks (mean difference = - 1.69 mmHg [- 2.22, - 1.16], P < 0.001). In the RKI versus another medication class, IOP reduction by RKI was noninferior to timolol 0.5% twice-daily after 4-8 weeks (mean difference = 0.39 mmHg [0.01, 0.76], P = 0.043) and 12 weeks (mean difference = 0.48 mmHg [0.11, 0.85]; P = 0.011). In the subgroup analysis, the mean difference in IOP reduction by adjunctive RKI and placebo was - 1.42 mmHg (P < 0.001). The most common ocular AE of RKI was conjunctival hyperemia (19-65%), followed by conjunctival hemorrhage (6-20%) and cornea verticillata (13-26%). CONCLUSIONS With a treatment duration of 1-3 months, RKI showed effective IOP reduction noninferior to timolol as monotherapy and as adjunctive therapy. Our results suggested RKI be a reliable IOP control medication; however, its higher incidence of some ocular complications should be attended to.
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Affiliation(s)
- Jo-Hsuan Wu
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California, San Diego, CA, USA
| | - Sheng-Nan Chang
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Medicine, National Taiwan University Hospital YunLin Branch, 579 Yunlin Road, Section 2, DouLiu City, Yunlin County, Taiwan
| | - Takashi Nishida
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California, San Diego, CA, USA
- Department of Ophthalmology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Bo-I Kuo
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Ophthalmology, Taipei City Hospital, Renai Branch, Taipei, Taiwan
| | - Jou-Wei Lin
- Department of Medicine, National Taiwan University Hospital YunLin Branch, 579 Yunlin Road, Section 2, DouLiu City, Yunlin County, Taiwan.
- Department of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
- Department of Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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22
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Liu P, Wang F, Song Y, Wang M, Zhang X. Current situation and progress of drugs for reducing intraocular pressure. Ther Adv Chronic Dis 2022; 13:20406223221140392. [PMID: 36479139 PMCID: PMC9720821 DOI: 10.1177/20406223221140392] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 11/03/2022] [Indexed: 12/05/2022] Open
Abstract
Glaucoma, the most common cause of irreversible blindness worldwide, usually causes characteristic optic nerve damage. Pathological intraocular pressure (IOP) elevation is a major risk factor. Drug reduction of IOP is the preferred treatment for clinicians because it can delay the progression of disease. However, the traditional IOP-lowering drugs currently used by patients may be poorly tolerated. Therefore, in recent years, some new drugs have been put into clinical application or in clinical phase I–III studies. They have a better IOP-lowering effect and fewer adverse reactions. Because glaucoma is a chronic disease, drugs need to be administered continuously for a long time. For patients, good compliance and high drug bioavailability have a positive effect on the prognosis of the disease. Therefore, clinicians and scientists have developed drug delivery systems to solve this complex problem. In addition, natural compounds and dietary supplements have a good effect of reducing IOP, and they can also protect the optic nerve through antioxidant action. We summarize the current traditional drugs, new drugs, sustained-release drug delivery systems, and complementary drugs and outline the mechanism of action and clinical effects of these drugs on glaucoma and their recent advances.
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Affiliation(s)
- Peiyu Liu
- Jiangxi Provincial Key Laboratory for Ophthalmology, Nanchang University School of Ophthalmology & Optometry, Jiangxi Research Institute of Ophthalmology & Visual Science, Affiliated Eye Hospital of Nanchang University, Nanchang, China
| | - Feifei Wang
- Jiangxi Provincial Key Laboratory for Ophthalmology, Nanchang University School of Ophthalmology & Optometry, Jiangxi Research Institute of Ophthalmology & Visual Science, Affiliated Eye Hospital of Nanchang University, Nanchang, China
| | - Yuning Song
- Jiangxi Provincial Key Laboratory for Ophthalmology, Nanchang University School of Ophthalmology & Optometry, Jiangxi Research Institute of Ophthalmology & Visual Science, Affiliated Eye Hospital of Nanchang University, Nanchang, China
| | - Menghui Wang
- Jiangxi Provincial Key Laboratory for Ophthalmology, Nanchang University School of Ophthalmology & Optometry, Jiangxi Research Institute of Ophthalmology & Visual Science, Affiliated Eye Hospital of Nanchang University, Nanchang, China
| | - Xu Zhang
- Jiangxi Provincial Key Laboratory for Ophthalmology, Nanchang University School of Ophthalmology & Optometry, Jiangxi Research Institute of Ophthalmology & Visual Science, Affiliated Eye Hospital of Nanchang University, 463 Bayi Road, Nanchang 330006, China
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Wang T, Cao L, Jiang Q, Zhang T. Topical Medication Therapy for Glaucoma and Ocular Hypertension. Front Pharmacol 2021; 12:749858. [PMID: 34925012 PMCID: PMC8672036 DOI: 10.3389/fphar.2021.749858] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/16/2021] [Indexed: 11/17/2022] Open
Abstract
Glaucoma is one of the most common causes of blindness, thus seriously affecting people’s health and quality of life. The topical medical therapy is as the first line treatment in the management of glaucoma since it is inexpensive, convenient, effective, and safe. This review summarizes and compares extensive clinical trials on the topical medications for the treatment of glaucoma, including topical monotherapy agents, topical fixed-combination agents, topical non-fixed combination agents, and their composition, mechanism of action, efficacy, and adverse effects, which will provide reference for optimal choice of clinical medication. Fixed-combination therapeutics offer greater efficacy, reliable security, clinical compliance, and tolerance than non-fixed combination agents and monotherapy agents, which will become a prefer option for the treatment of glaucoma. Meanwhile, we also discuss new trends in the field of new fixed combinations of medications, which may better control IOP and treat glaucoma.
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Affiliation(s)
- Tao Wang
- Department of Pharmaceutics, Wuya College of Innovation, Shenyang Pharmaceutical University, Shenyang, China
| | - Linlin Cao
- Department of Pharmaceutics, The Second Hospital of Dalian Medical University, Dalian, China
| | - Qikun Jiang
- Department of Pharmaceutics, Wuya College of Innovation, Shenyang Pharmaceutical University, Shenyang, China
| | - Tianhong Zhang
- Department of Pharmaceutics, Wuya College of Innovation, Shenyang Pharmaceutical University, Shenyang, China
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Zaman F, Gieser SC, Schwartz GF, Swan C, Williams JM. A multicenter, open-label study of netarsudil for the reduction of elevated intraocular pressure in patients with open-angle glaucoma or ocular hypertension in a real-world setting. Curr Med Res Opin 2021; 37:1011-1020. [PMID: 33733980 DOI: 10.1080/03007995.2021.1901222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Assess the real-world efficacy of netarsudil, either as monotherapy or concomitant therapy, in patients with open-angle glaucoma (OAG) or ocular hypertension (OHT) requiring modification of intraocular pressure (IOP)-lowering treatment. METHODS Multicenter, prospective, interventional, open-label, Phase 4 study, clinical trial registration number: NCT03808688. Netarsudil ophthalmic solution 0.02% was prescribed at the recommended once-daily dosage, with treatment regimens determined by the investigators. Netarsudil could be used alone or in combination with other IOP-lowering medications, consistent with standard clinical practice. Primary efficacy endpoint: percentage reduction from baseline IOP at week 12. RESULTS Among 261 enrolled patients, 242 received ≥1 netarsudil dose and had ≥1 follow-up IOP measurement (efficacy population). Mean IOP in patients who were treatment-naïve at baseline and using netarsudil as monotherapy (n = 24) decreased by 16.9%. Netarsudil monotherapy was comparable in efficacy to prior therapy across subgroups, and those who replaced prostaglandin analog (n = 57) monotherapy demonstrated reduction of 2.5% from prostaglandin analog-treated baseline values. Among patients who used netarsudil as concomitant therapy (n = 151), reductions in mean IOP (± standard deviation) to week 12 were seen across subgroups who added netarsudil to a single agent (4.3 ± 2.88 mmHg; 20.5%) or ≥2 classes of concomitant therapy (4.5 ± 4.08 mmHg; 20.9%) and who used netarsudil to replace ≥1 other drug classes (0.4 ± 2.47 mmHg; 1.7%). Of 260 netarsudil-treated patients, 41 (15.8%) discontinued, including 29 (11.2%) due to adverse events. CONCLUSIONS In the real-world treatment of patients with OAG or OHT, netarsudil consistently maintained IOP control when it replaced previous IOP-lowering therapies and provided additional IOP-lowering efficacy when added to other treatments.
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Affiliation(s)
- Fiaz Zaman
- Houston Eye Associates, Houston, TX, USA
| | | | | | - Cayla Swan
- Aerie Pharmaceuticals, Inc., Durham, NC, USA
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25
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Nobl M, Mackert M. Pigmentdispersionssyndrom. AUGENHEILKUNDE UP2DATE 2021. [DOI: 10.1055/a-1352-7223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ZusammenfassungDas Pigmentdispersionssyndrom ist eine Erkrankung, die durch Abschilferung von
Pigment aus dem Irispigmentepithel und dessen Ablagerung im vorderen
Augenabschnitt charakterisiert ist. Typisch ist eine Trias aus Ablagerungen am
Hornhautendothel, zirkulären Iristransilluminationen und einer Pigmentierung des
Trabekelwerks. Das Spektrum reicht vom einfachen Pigmentdispersionssyndrom bis
zum Pigmentdispersionsglaukom mit Optikusatrophie.
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Nobl M, Mackert M. [Pigment Dispersion Syndrome]. Klin Monbl Augenheilkd 2021. [PMID: 33873208 DOI: 10.1055/a-1472-0471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Pigment dispersion syndrome (PDS) is a disorder predominantly affecting young, myopic adults. It is characterised by the liberation of pigment of the iris and deposition of it on various structures of the anterior segment leading to multiple specific findings in slit lamp examination. Typical alterations are a deposition of pigment on the central corneal endothelium, circular iris transillumination defects in the mid periphery, a posterior bowing of the iris and increased pigmentation of the trabecular meshwork. Findings are usually bilateral symmetric. Posterior bowing of the iris causes rubbing of the pigmented iris epithelium against lens structures like zonular fibres with a consecutive liberation of pigment. Trabecular meshwork changes because of pigment deposition reduce aqueous outflow facility with the risk of elevated intraocular pressure and glaucoma. Pigmentary glaucoma (PG) is a secondary open angle glaucoma. Treatment of PG is similar to primary open angle glaucoma, including medical therapy, laser therapy and surgery. Peripheral laser iridotomy was shown to change iris configuration but its efficacy in the prevention of PG has not been confirmed in the literature. The purpose of this paper is to summarize information regarding ocular manifestations of PDS to facilitate an early diagnosis and to present a general view of the treatment of PG.
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Araie M, Sugiyama K, Aso K, Kanemoto K, Kothapalli K, Kopczynski C, Senchyna M, Hollander DA. Phase 2 Randomized Clinical Study of Netarsudil Ophthalmic Solution in Japanese Patients with Primary Open-Angle Glaucoma or Ocular Hypertension. Adv Ther 2021; 38:1757-1775. [PMID: 33629227 PMCID: PMC8004483 DOI: 10.1007/s12325-021-01634-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 01/19/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Netarsudil reduces intraocular pressure (IOP) by increasing aqueous outflow through the trabecular meshwork (TM) pathway and decreasing episcleral venous pressure. The primary objective of this phase 2 study was to evaluate ocular hypotensive efficacy and safety of three netarsudil concentrations (0.01%, 0.02%, and 0.04%) relative to its placebo over 4 weeks in Japanese patients with primary open-angle glaucoma (POAG) or ocular hypertension (OHT). METHODS Patients were randomized to one of four treatment arms, netarsudil ophthalmic solution 0.01%, 0.02%, 0.04%, or placebo, and treated once-daily (QD) in the evening (P.M.) for 4 weeks. The primary efficacy variable was mean diurnal IOP (average of diurnal time points at 9 A.M., 11 A.M., and 4 P.M.) at week 4. RESULTS A total of 215 patients were randomized and 207 (96.3%) completed the study. The mean of mean diurnal IOP at baseline ranged from 20.28 to 21.14 mmHg across groups. At week 4, least squares (LS) mean of mean diurnal IOP adjusted for baseline was 16.53, 15.82, 16.06, and 18.94 mmHg in the netarsudil 0.01%, 0.02%, 0.04%, and placebo groups, respectively, demonstrating the superiority of netarsudil (all concentrations) over placebo. At week 4, mean reduction (mean percentage reduction) from baseline in mean diurnal IOP was 4.10 (19.8%), 4.80 (23.5%), 4.81 (23.8%), and 1.73 mmHg (8.2%), respectively, demonstrating statistically significant reductions (p < 0.0001) in all netarsudil concentrations over placebo. Adverse events (AEs) occurred in a concentration-dependent manner, and the incidence of ocular AEs was 34.5%, 42.6%, 68.6%, and 9.1% in the netarsudil 0.01%, 0.02%, 0.04%, and placebo groups, respectively. The most frequently reported AE was conjunctival hyperemia, with an incidence of 23.6%, 37.0%, 56.9%, and 1.8%, respectively. No serious AEs were reported. CONCLUSION Netarsudil ophthalmic solutions 0.01%, 0.02%, and 0.04% dosed QD (P.M.) demonstrated superiority to placebo in terms of hypotensive effectiveness at week 4 and were found to be safe and generally well tolerated. Netarsudil 0.02% QD provided an optimal efficacy and safety profile for the treatment of Japanese patients with POAG or OHT. TRIAL REGISTRATION NCT03844945.
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Affiliation(s)
- Makoto Araie
- Kanto Central Hospital of the Mutual Aid Association of Public School Teachers, Tokyo, Japan.
| | - Kazuhisa Sugiyama
- Department of Ophthalmology, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan
| | - Kenji Aso
- Aerie Pharmaceuticals Ireland Ltd. (Japan Branch), Tokyo, Japan
| | - Koji Kanemoto
- Aerie Pharmaceuticals Ireland Ltd. (Japan Branch), Tokyo, Japan
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Al-Humimat G, Marashdeh I, Daradkeh D, Kooner K. Investigational Rho Kinase Inhibitors for the Treatment of Glaucoma. J Exp Pharmacol 2021; 13:197-212. [PMID: 33664600 PMCID: PMC7921633 DOI: 10.2147/jep.s259297] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/07/2021] [Indexed: 01/27/2023] Open
Abstract
This review provides a comprehensive update on emerging ROCK inhibitors as an innovative treatment option for lowering intraocular pressure (IOP) in glaucoma and aims to describe the structure, mechanism of action, pharmaceutical characteristics, desirable ocular effects, including side effects for each agent. A literature review was conducted using PubMed, Scopus, clinicaltrials.gov, ARVO journals, Cochrane library and Selleckchem. Databases were searched using "investigational Rho kinase inhibitors," and "glaucoma" as keywords. In addition to this building block strategy, successive fractions were employed to further refine the results. Of the several ROCK inhibitors discovered, only two drugs are currently approved for glaucoma treatment; Netarsudil in the USA and Ripasudil in Japan and China. We identified and reviewed 15 agents currently in laboratory or clinical trials. These agents lower IOP mainly by decreasing outflow resistance through pharmacologic relaxation of the trabecular meshwork (TM) cells and reducing episcleral venous pressure. They have an optimistic safety profile; however, conjunctival hyperemia, conjunctival hemorrhage, pain on instillation, and corneal verticillata are common. Other properties such as neuroprotection (enhancing optic nerve blood flow and promoting axonal regeneration), anti-fibrotic activity, and endothelial cell proliferation may improve the visual prognosis and surgical outcomes in glaucoma. In addition, these agents have the potential to work synergistically with other topical glaucoma medications.
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Affiliation(s)
- Ghadeer Al-Humimat
- Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Ophthalmology, King Hussein Medical Center, Amman, Jordan
| | - Ibtisam Marashdeh
- Department of Ophthalmology, King Hussein Medical Center, Amman, Jordan
| | - Duaa Daradkeh
- Department of Ophthalmology, King Hussein Medical Center, Amman, Jordan
| | - Karanjit Kooner
- Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Ophthalmology, Veteran Affairs North Texas Health Care System Medical Center Dallas, Dallas, TX, USA
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