A Double-Masked, Randomized, Parallel Comparison of a Fixed Combination of Bimatoprost 0.03%/Timolol 0.5% with Non-Fixed Combination use in Patients with Glaucoma or Ocular Hypertension

Effectiveness of Single-Tablet Combination Therapy in Improving Adherence and Persistence and the Relation to Clinical and Economic Outcomes

Background: Single-tablet combination therapies (STCTs) combine multiple drugs into one formulation, making drug administration more convenient for patients. STCTs were developed to address concerns with treatment adherence and persistence, but the impact of STCT use is not fully understood across indications. Objectives: We conducted a systematic literature review (SLR) to examine STCT-associated outcomes across 4 evidence domains: clinical trials, real-world evidence (RWE), health-related quality of life (HRQoL) studies, and economic evaluations. Methods: Four SLRs were conducted across the aforementioned domains. Included studies compared STCTs as well as fixed-dose combinations ([FDCs] of non-tablet formulations) with the equivalent active compounds and doses in loose-dose combinations (LDCs). Original research articles were included; case reports, case series, and non-English-language sources were excluded. Databases searched included EconLit, Embase, and Ovid MEDLINE® ALL. Two independent reviewers assessed relevant studies and extracted data. Conflicts were resolved with a third reviewer or consensus-based discussion. Results: In all, 109 studies were identified; 27 studies were identified in more than one SLR. Treatment adherence was significantly higher in patients receiving FDCs vs LDCs in 12 of 13 RWE studies and 3 of 13 clinical trials. All 18 RWE studies reported higher persistence with FDCs. In RWE studies examining clinical outcomes (n = 17), 14 reported positive findings with FDCs, including a reduced need for add-on medication, blood pressure control, and improved hemoglobin A1C. HRQoL studies generally reported numerical improvements with STCTs or similarities between STCTs and LDCs. Economic outcomes favored STCT use. All 6 cost-effectiveness or cost-utility analyses found FDCs were less expensive and more efficacious than LDCs. Four budget impact models found that STCTs were associated with cost savings. Medical costs and healthcare resource use were generally lower with FDCs than with LDCs. Discussion: Evidence from RWE and economic studies strongly favored STCT use, while clinical trials and HRQoL studies primarily reported similarity between STCTs and LDCs. This may be due to clinical trial procedures aimed at maximizing adherence and HRQoL measures that are not designed to evaluate drug administration. Conclusions: Our findings highlight the value of STCTs for improving patient adherence, persistence, and clinical outcomes while also offering economic advantages.

Fixed-combination topical anti-hypertensive ophthalmic agents

INTRODUCTION

Fixed-combination glaucoma medications have altered the paradigm of ocular hypertension and glaucoma treatment and are in widespread use today. A comprehensive review of fixed-combination medications will help educate and inform providers for optimal patient care.

AREAS COVERED

In this review, the authors describe the composition, mechanism of action, efficacy, side effects, and safety profile of fixed-combination agents for the treatment of ocular hypertension and glaucoma as well as comparisons between the most frequently prescribed medications.

EXPERT OPINION

Fixed-combination therapeutics provide an effective and efficient means of lowering intraocular pressure with comparable side effects and outcomes to constituent parts with lower patient exposure to preservatives and improvement in compliance.

Multiple drug delivery from the drug-implants-laden silicone contact lens: Addressing the issue of burst drug release

A fixed combination of bimatoprost/timolol eye drop solution is used to manage the elevated intra-ocular pressure in glaucoma patients, including individuals whose condition is poorly controlled by monotherapy. Eye drop solutions are generally given in high dose, due to poor ocular bioavailability. The high ocular dose of bimatoprost and timolol lead to hyperaemia and systemic cardiac side effects respectively. Here, we introduce multiple implant-laden contact lenses (IM) to passively deliver timolol, bimatoprost and hyaluronic acid at therapeutically relevant doses without high burst release. The drug-loaded implants were individually implanted in the outer periphery of the silicone contact lenses. Atomic force microscopy showed the smooth surface of the implant contact lens, as the implants were inside the contact lens matrix. The implant lens (IM) showed major loss of drugs [timolol = 60.60%, bimatoprost = 61.75% and HA = 46.03%] during the monomer extraction and wet sterilization, while the option of dry radiation sterilization (IM-R lens) and hydration for 24 h prior to use showed relatively lower loss of drugs [timolol = 16.87%, bimatoprost = 47.95% and HA = 24.41%]. The in-vitro drugs release data of IM-R lens, showed sustained release for 72 h, with low burst release in comparison to the soaked (SM) and direct drug-laden contact lenses (DL). The in vivo drug release data in the rabbit tear fluid showed sustained release using IM-R lens in comparison to the SM lens and eye drop therapy. The burst release with the IM-R lens was many folds reduced, which could bypass the side effects associated with multiple eye drop therapy. The in vivo pharmacodynamic study in the rabbit model showed peak and valley profile with multiple eye drop therapy, while IM-R lens showed prolong reduction in intra ocular pressure (IOP) for 120 h. The study demonstrates the application of implantation technology to deliver multiple drug through contact lenses to treat glaucoma.

[The role of fixed dose combinations in the treatment of primary open-angle glaucoma]

A great number of patients with primary open-angle glaucoma require combination therapy with several hypotensive drugs of different pharmacological groups to efficiently compensate the intraocular pressure (IOP) and prevent further development of glaucoma. Although glaucoma treatment usually starts with monotherapy, several preparations administered simultaneously have stronger hypotensive effect further increased by their additive action. However, the increased frequency of instillations may lead to drug washout and decreased patient compliance. Fixed dose combinations (FDCs) are a pharmacological form of eye drops that combines two or more active drugs in a single dosage form. The frequency of FDCs administration does not exceed two per day, which is convenient for long-term application and helps improve patient compliance. FDCs tolerability tends to be higher than that of simultaneous instillations of separate monotherapy drugs, while the hypotensive in clinical trials is comparable, in some real practice trials is superior. A review of existing studies showed that FDCs are superior to monotherapy in terms of cost-effectiveness. The use of FDCs was found to be beneficial for glaucoma treatment from the viewpoints of both reaching the target IOP for preserving visual functions in glaucoma patients, and minimizing the long-term treatment costs.

Efficacy of Timolol 0.1% Gel and a Prostaglandin Analog in an Unfixed Combination Compared to the Corresponding Fixed Combinations

PURPOSE

To investigate the intraocular pressure (IOP) reduction with prostaglandin analogs (PGAs)-timolol fixed combinations versus the unfixed combination of the same PGAs and timolol 0.1% in gel-forming carbomer.

METHODS

Patients with primary open-angle glaucoma (POAG) receiving for at least 4 weeks the fixed combinations of PGA-timolol, administered once a day in the evening (0.005% latanoprost with 0.5% timolol, 0.004% travoprost with 0.5% timolol, 0.03% bimatoprost with 0.5% timolol) were switched to an unfixed combination of the same PGA (once a day in the evening) with timolol 0.1% in gel-forming carbomer (once a day in the morning) for at least 4 weeks. The primary endpoint was to compare efficacy of fixed vs unfixed combinations in lowering IOP. The effects of both regimens on short-term IOP fluctuations were also assessed.

RESULTS

A total of 32 patients (64 eyes) fulfilled inclusion criteria: 17 patients received latanoprost-timolol fixed combination, 9 travoprost-timolol fixed combination, 6 bimatoprost-timolol fixed combination. For all considered time periods each unfixed combination induced an IOP reduction significantly higher than the corresponding fixed combination (paired t test: p<0.05 in all measurements). The diurnal IOP reduction was significantly higher during the unfixed combinations (p<0.001). Unfixed combinations significantly decreased IOP diurnal fluctuations and increased the percentage of patients with daily IOP fluctuation ≤2 mm Hg.

CONCLUSIONS

In this pilot study, PGA and timolol seems to be more effective in POAG treatment when administered as unfixed combinations, reducing both IOP and daily fluctuations. The once a day timolol 0.1% gel-forming carbomer may be a valuable option in PGA-timolol unfixed combination regimen.

Ophthalmologist Attitudes regarding Fixed Combination Treatment for Glaucoma in the European Union

Purpose

To survey ophthalmologists in the European Union to determine their fixed combination (FC) preferences.

Methods

A multiple-choice survey was sent to randomly chosen ophthalmologists throughout the European Union and bordering countries by electronic mail delivery. Ophthalmologists were resent the survey on two more occasions if no response was obtained.

Results

In total, 50 surveys were received from 530 distributed (9.4% response) from 16 countries. More ophthalmologists prescribed an FC as second (80%) or third choice (64%) therapy than first choice (30%, p=0.0036). As first (p<0.0001) and third choice (p=0.011), the dorzolamide/timolol FC was most commonly prescribed, while as second choice the latanoprost/timolol FC (p<0.0001) was most popular. Overall, 98% (49/50) of doctors believed FC therapy improved patient care most often by better compliance (n=49) and quality of life (n=48, p<0.0001). Most ophthalmologists believed that there was a difference in efficacy between the FC products (32/50, 64%) with the most effective being the bimatoprost/timolol FC (n=12, 24%, p=0.029). However, fewer ophthalmologists perceived safety differences between the products (34/50, 68%). For prostaglandins, dosing time was suggested in the morning by 18 (36%) ophthalmologists and in the evening by 24 (48%) (p=0.35).

Conclusions

FCs in the European Union are a potentially popular method to reduce intraocular pressure, being prescribed most commonly as second or third choice therapy. The perceived advantages to FC therapy are greater compliance to the medicine and improved patient quality of life.

Efficacy of the Fixed Combinations of Bimatoprost or Latanoprost plus Timolol in Patients Uncontrolled with Prostaglandin Monotherapy: A Multicenter, Randomized, Investigator-Masked, Clinical Study

Purpose

To compare the efficacy and tolerability of a once-daily evening dose of bimatoprost/timolol fixed combination (BTFC) with that of a once-daily evening dose of latanoprost/timolol fixed combination (LTFC) in patients not controlled with prostaglandins analogues monotherapy.

Methods

A total of 82 patients on prostaglandin analogues monotherapy were enrolled in this prospective, multicenter, investigator masked, clinical study and were randomized to either BTFC (n=47) or LTFC (n=35) topical therapy once at night for 12 weeks. The primary endpoint of the study was to compare the mean daily intraocular pressure (IOP) reduction from baseline between the two treatment arms. Secondary endpoints included the mean daily IOP at 1 and 3 months compared to baseline and the percentage of patients showing a mean IOP reduction from baseline greater than or equal to 15% or 20%.

Results

Mean IOP at baseline was 22.7±2.0 and 22.1±2.6 mmHg in the BTFC and LTFC groups, respectively (p=0.23). Both treatments were effective in reducing the IOP from baseline. The mean IOP reduction was significantly greater in the BTFC group than in the LTFC group (–21.4% vs −13.7%, p<0.001). A higher percentage of patients in the BTFC group showed a mean IOP reduction from baseline ≥ 15% (72.3% vs 40.0%) and ≥ 20% (61.7% vs 17.1%) compared to patients in the LTFC group.

Conclusions

Both BTFC and LTFC were more effective versus the monotherapy with prostaglandin analogues. BTFC demonstrated higher performance than LTFC in terms of relative IOP reduction.

Efficacy of Bimatoprost Plus Timolol Fixed Combination in Open Angle Glaucoma Patients Previously Treated with Dorzolamide Plus Timolol Fixed Combination

PURPOSE

To evaluate the efficacy and safety of bimatoprost plus timolol fixed combination (BTFC) in patients with primary open angle glaucoma (POAG) previously treated with dorzolamide plus timolol fixed combination (DTFC).

MATERIALS AND METHODS

Retrospective, medical records review study. Medical records of patients with POAG previously treated with DTFC and then switched to BTFC for poor intraocular pressure (IOP) control or ocular discomfort were included in the analysis. One baseline IOP diurnal curve, and one diurnal curve under each treatment were required to be eligible for this study. The primary outcome was to compare the mean diurnal IOP between DTFC and BTFC. Secondary outcomes were to compare the IOP diurnal fluctuation, and the percentage of patients achieving a target IOP <14, <16, and <18 mmHg between the two treatments.

RESULTS

Medical records of 96 patients were analyzed (mean age 65.8 years ± 7.2, range 39-89 years). The mean diurnal IOP was 23.7 ± 3.8 mmHg at baseline, 16.9 ± 3.4 mmHg with DTFC and 15.1 ± 2.9 mmHg after therapy was switched to BTFC (p < 0.0001 each treatment vs baseline; p < 0.0001 DTFC vs BTFC). The proportion of patients achieving a mean diurnal IOP <18, <16, and <14 mmHg was 76%, 35.4%, and 12.5% with DTFC and 81.2%, 68.8%, and 37.5% with BTFC (p = 0.20, p < 0.01, and p < 0.0001 between the two treatments, respectively). IOP fluctuation did not differ significantly between the treatments.

CONCLUSION

BTFC can provide additional lowering in the mean diurnal IOP in patients previously treated with DTFC with no significant differences in the safety and tolerability profile.

Acute Corneal Toxicity of Combined Antiglaucoma Topical Eyedrops

PURPOSE

To investigate the corneal toxicity of three combined antiglaucoma topical eyedrops using transepithelial electrical resistance (TER) and scanning electron microscopy (SEM).

METHODS

Corneal TER changes after a 60-s exposure to latanoprost/timolol with 0.02% benzalkonium chloride (BAC), travoprost/timolol with polyquaternium-1, and dorzolamide/timolol with 0.005% BAC were measured in living rabbits. Corneal damage was also examined by SEM. Hank's balanced salt solution (HBSS) was used as a control.

RESULTS

There was a significant decrease in the corneal TER after exposure of the cornea to latanoprost/timolol with 0.02% BAC. Travoprost/timolol with polyquaternium-1 and dorzolamide/timolol with 0.005% BAC did not produce any significant decrease in the corneal TER as compared to HBSS control eyes. SEM revealed that superficial cells of corneas treated with latanoprost/timolol with 0.02% BAC were damaged and exhibited degenerated microvilli. Conversely, the superficial cells of corneas exposed to travoprost/timolol with polyquaternium-1 or dorzolamide/timolol with 0.005% BAC appeared normal and had normal microvilli under SEM examinations.

CONCLUSION

The corneal toxicity of latanoprost/timolol with 0.02% BAC is greater than that of travoprost/timolol with polyquaternium-1 and dorzolamide/timolol with 0.005% BAC. Latanoprost/timolol contains 0.02% BAC, which may be responsible for the corneal toxicity.

Efficacy and tolerability of fixed-combination bimatoprost/timolol versus fixed-combination dorzolamide/brimonidine/timolol in patients with primary open-angle glaucoma or ocular hypertension: a multicenter, prospective, crossover study

BACKGROUND

Fixed-combination ocular hypotensives have multiple advantages, but triple-therapy dorzolamide/brimonidine/timolol (dorz/brim/tim) is only available in Latin and South America, and information on its relative efficacy is limited. This study compares the efficacy and tolerability of fixed-combination bimatoprost/timolol (bim/tim) and dorz/brim/tim in Mexican patients with primary open-angle glaucoma or ocular hypertension.

METHODS

In this investigator-masked, crossover study, patients with unmet target intraocular pressure (IOP) on once-daily bim/tim or twice-daily dorz/brim/tim received the opposite medication for 3 months before returning to their pre-baseline medication for 3 months. IOP was evaluated before and after morning instillation at months 2, 3, 5 and 6. Primary endpoints were mean IOP change and Ocular Surface Disease Index© (OSDI) score at each visit. The intent-to-treat population was the a priori analysis population, but due to the number of discontinuations, the per-protocol and intent-to-treat populations were used for the primary efficacy and sensitivity analyses, respectively.

RESULTS

Seventy-eight and 56 patients were included in the intent-to-treat and per-protocol populations, respectively. At month 3, statistically significant IOP reductions from baseline were observed in the bim/tim (P < 0.01) and dorz/brim/tim (P < 0.0001) groups, regardless of assessment time. At month 6, patients returned to bim/tim exhibited no significant IOP increase (regardless of assessment time), but patients returned to dorz/brim/tim exhibited a statistically significant IOP increase (P < 0.001) when assessed before instillation of study treatment. Results were similar in both intent-to-treat and per-protocol analysis populations. In the per-protocol analysis, 70% of patients on bim/tim at month 3 had an IOP <14 mm Hg, which declined to 58% (P = 0.0061) at month 6 (ie, after 3 months of dorz/brim/tim treatment). In patients receiving dorz/brim/tim at month 3, 38% had an IOP <14 mm Hg, which remained comparable after return to bim/tim. OSDI scores and incidence of adverse events were similar in both groups.

CONCLUSIONS

In this first direct comparison of the efficacy of dorz/brim/tim and bim/tim, patients switched from dorz/brim/tim to bim/tim demonstrated improved/lower IOP; when returned to dorz/brim/tim, IOP increased to levels seen at study initiation, suggesting that once-daily bim/tim may have greater IOP-lowering efficacy. Both bim/tim and dorz/brim/tim were well tolerated with minimal ocular surface damage.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01737853 (registered October 9, 2012).

Brinzolamide plus brimonidine for the treatment of glaucoma: an update

INTRODUCTION

Glaucoma is a common sight-threatening condition that is primarily treated by lowering intraocular pressure (IOP). Today the mainstay of treatment is topical ocular hypotensive medications; many patients require more than one agent to achieve target IOP. For such patients, fixed combination formulations have several advantages including simplicity of treatment regimen, adherence to the treatment regimen, efficacy, improved ocular surface comfort and reduced cost. All currently available fixed combinations contain a β-blocker, which is contraindicated in some patients. Hence there is a clinical need for fixed-combination preparations without a β-blocker. This paper reviews the current literature on a new fixed-combination drug containing brinzolamide 1% and brimonidine 0.2% (BBFC).

AREAS COVERED

A PubMed, Embase and ClinicalTrials.gov registry search was performed to identify all relevant studies. Four published clinical papers pertaining to three randomized controlled trials were identified for review. All studies demonstrated a significant reduction (p < 0.01) in mean IOP in patients administered with BBFC compared with its individual components, brinzolamide 1% or brimonidine 0.2%. Adverse effects from BBFC were no different from each of the individual components, the most common being blurred vision, eye irritation and dysgeusia (abnormal taste sensation). Although BBFC use was associated with more adverse effects compared with the individual components used as monotherapy (p < 0.001), the cumulative adverse effect profile from BBFC did not appear greater than one would expect from the simultaneous use of the two components.

EXPERT OPINION

BBFC is a potential alternative to other fixed-combination medications and is especially useful when topical β-blockers are contraindicated. Longer-term experience will determine if additional adverse effects occur or if efficacy is maintained over longer periods.

Fixed-dose combination of tafluprost and timolol in the treatment of open-angle glaucoma and ocular hypertension: comparison with other fixed-combination products

A new preservative-free fixed-dose combination of 0.0015% tafluprost, a prostaglandin F_2α analog, and 0.5% timolol (TAF/TIM; Santen Oy, Tampere, Finland), a beta-adrenergic antagonist has recently been developed. The intraocular pressure (IOP) reduction with TAF/TIM in open-angle glaucoma and ocular hypertension is similar to that of other prostaglandin–timolol fixed-combination products. Patients with high IOP responded well to TAF/TIM with reductions of up to 40% (>13 mmHg) and beyond. Compared to previous controlled and double-masked clinical trials with DuoTrav^® (Alcon, Fort Worth, USA) and Ganfort^® (Allergan, Irvine, USA), TAF/TIM caused less superficial ocular side effects and less conjunctival hyperemia. Plausible explanations for the differences in side effects between the fixed-combination products are discussed.

Bimatoprost 0.03%/timolol 0.5% preservative-free ophthalmic solution versus bimatoprost 0.03%/timolol 0.5% ophthalmic solution (Ganfort) for glaucoma or ocular hypertension: a 12-week randomised controlled trial

AIM

To compare the efficacy and safety of single-dose bimatoprost 0.03%/timolol 0.5% preservative-free (PF) ophthalmic solution with bimatoprost 0.03%/timolol 0.5% ophthalmic solution in patients with open-angle glaucoma or ocular hypertension.

METHODS

In this multicentre, randomised, parallel-group study, patients were randomised to bimatoprost/timolol PF or bimatoprost/timolol once daily in the morning for 12 weeks. Primary efficacy endpoints, reflecting differing regional regulatory requirements, included change from baseline in worse eye intraocular pressure (IOP) in the per-protocol population at week 12, and the average eye IOP at weeks 2, 6 and 12 in the intent-to-treat population.

RESULTS

561 patients were randomised (278 to bimatoprost/timolol PF; 283 to bimatoprost/timolol); 96.3% completed the study. Both treatment groups showed statistically and clinically significant mean decreases from baseline in worse eye IOP and in average eye IOP at all follow-up time points (p<0.001). Bimatoprost/timolol PF met all pre-established criteria for non-inferiority and equivalence to bimatoprost/timolol. Ocular adverse events were similar between treatment groups, with conjunctival hyperaemia being the most frequent. Most were mild or moderate in severity.

CONCLUSIONS

Bimatoprost/timolol PF demonstrated non-inferiority and equivalence in IOP lowering compared with bimatoprost/timolol, with no significant differences in safety and tolerability.

TRIAL REGISTRATION NUMBER

NCT01177098.

Intraocular pressure-lowering combination therapies with prostaglandin analogues

Intraocular pressure (IOP) reduction is currently the only therapeutic approach demonstrated to preserve visual function in patients with glaucoma. The first line of glaucoma treatment consists of topical IOP-lowering medications, usually initiated as monotherapy. A significant proportion of patients require more than one medication to reach a target IOP at which optic nerve damage will not progress. As prostaglandin analogues (PGAs) are the most effective class for reducing IOP, one of the other commonly used classes (β-adrenoceptor antagonist [β-blocker], carbonic anhydrase inhibitor or α(2)-adrenoceptor agonist) is frequently combined with a PGA. In the last decade, the use of fixed combinations containing two medications in a single bottle has steadily increased. Fixed combinations have the potential to simplify the dosing regimen, increase patient adherence, avoid the washout effect of the second drop on the first medication instilled, decrease exposure to preservatives and, sometimes, reduce the cost of treatment. Clinical trials have evaluated PGA-based fixed combinations versus unfixed combinations (individual components administered concomitantly) or versus individual monotherapies; however, any advantage that the fixed combinations may have in terms of IOP-lowering efficacy is still debated. For these reasons, the PGA-based fixed combinations are not approved by regulatory authorities in some countries, such as the US. We review the published studies evaluating the efficacy and tolerability of the IOP-lowering unfixed and fixed combination therapies with PGAs. Regarding unfixed combinations, the review shows that α(2)-adrenergic agonists-PGA and carbonic anhydrase inhibitor-PGA combinations seem to be at least as effective at reducing IOP as the β-blocker-PGA combinations. As for the fixed combinations, the review shows that the three PGA-timolol fixed combinations are more effective than their component medications used separately as monotherapy and are better tolerated than the three respective prostaglandins. The three PGA-timolol fixed combinations are less effective at reducing IOP than the unfixed combinations but are better tolerated. The advantage of the fixed combinations in terms of patient adherence and persistence is supported by a very small number of studies and remains to be more accurately determined. Most studies, but not all, seem to show that PGA-timolol fixed combinations are more effective than other available β-blocker fixed combinations (dorzolamide-timolol fixed combinations) at reducing IOP and are similarly tolerated.

Ophthalmic drug discovery: novel targets and mechanisms for retinal diseases and glaucoma

Blindness affects 60 million people worldwide. The leading causes of irreversible blindness include age-related macular degeneration, retinal vascular diseases and glaucoma. The unique features of the eye provide both benefits and challenges for drug discovery and delivery. During the past decade, the landscape for ocular drug therapy has substantially changed and our knowledge of the pathogenesis of ophthalmic diseases has grown considerably. Anti-angiogenic drugs have emerged as the most effective form of therapy for age-related macular degeneration and retinal vascular diseases. Lowering intraocular pressure is still the mainstay for glaucoma treatment but neuroprotective drugs represent a promising next-generation therapy. This Review discusses the current state of ocular drug therapy and highlights future therapeutic opportunities.

Clinical options for the reduction of elevated intraocular pressure

Elevated IOP in clinical practice is usually seen in glaucoma or ocular hypertension. Glaucoma affects 60 million people worldwide and 8.4 million are bilaterally blind from this chronic disease.1 Options for reducing IOP rely on pharmacological agents, laser treatments and surgery which may be penetrating or non-penetrating. The last twenty years has seen significant changes in all of these strategies. This review aims to cover these clinical options and introduce some of the new technologies currently in development for the clinical lowering of IOP.

Efficacy and tolerability of prostaglandin-timolol fixed combinations: a meta-analysis of randomized clinical trials

PURPOSE

To evaluate the intraocular pressure (IOP)-lowering effects and tolerability of the 3 prostaglandin-timolol fixed combinations (PG-timolol FCs).

METHODS

Clinical trials comparing directly the PG-timolol FCs or comparing the PG-timolol FCs to their individual components were thoroughly searched. The main outcome measures were efficacy assessed by IOP (taken at 9 am, noon, 4 pm, and over the mean diurnal curve) change at 3 months (or after 1 to 6 months of treatment if no data were available at month 3) from baseline and tolerability assessed by the incidence of conjunctival hyperemia.

RESULTS

Twenty trials were identified (n = 4684 patients). Intraocular pressure reduction was usually greater with the 3 PG-timolol FCs than the individual PG (mean difference [MD] 0.00 mmHg to 2.59 mmHg; p>0.1 to p<0.001). The incidence of hyperemia was significantly less with latanoprost- and bimatoprost-timolol FCs than with the individual PG (relative risk = 0.66 and 0.61; p = 0.05 and p<0.001). From direct comparisons, IOP reduction was significantly greatest with bimatoprost-timolol FC, at 9 am, 4 pm, and over the mean diurnal curve compared to latanoprost-timolol FC (MD = 0.90 mmHg to 1.48 mmHg; p<0.001) and at all time points compared to travoprost-timolol FC (MD = 0.66 mmHg to 0.90 mmHg; p<0.001). The incidence of hyperemia was not significantly less with latanoprost-timolol FC than with bimatoprost-timolol FC (relative risk = 1.32; p>0.1).

CONCLUSIONS

The 3 PG-timolol FCs provide a greater IOP reduction and lower incidence of hyperemia than the 3 PGs alone. The direct comparisons suggest a greater efficacy of the bimatoprost-timolol FC compared with latanoprost- and travoprost-timolol FCs.

Topical prostaglandin fixed combinations in UK primary care: observational study using data from the health improvement network

PURPOSE

To describe the use of 3 prostaglandin/timolol fixed combinations (FCs) in UK primary care, to summarize characteristics of recipients, and to assess 12-month persistence.

METHODS

This retrospective cohort study included first-time recipients of latanoprost/timolol FC, bimatoprost/timolol FC, or travoprost/timolol FC treated between April 1, 2007, and November 30, 2008, identified in The Health Improvement Network database, a large database of anonymized longitudinal electronic medical records of patients treated in UK primary care. Eligible patients were = 18 years old at the index date (date of first prescription). Persistence, defined as a gap =60 days between consecutive prescriptions, was assessed through 12 months post-index for each cohort (Cox proportional hazards models).

RESULTS

A total of 2,015 patients were included: latanoprost/timolol FC, n = 898 (44.6%); bimatoprost/timolol FC, n = 733 (36.4%); travoprost/timolol FC, n = 384 (19.1%). The mean age was approximately 72 years across cohorts (p = 0.792). Glaucoma was the diagnosis for >90% of patients in each cohort. Twelve-month persistence was similar across treatments: latanoprost/timolol FC: 38.2%; bimatoprost/timolol FC: 38.6%; travoprost/timolol FC: 38.3% (p = 0.985). Mean time to therapy change for nonpersistent patients was also similar: 143.3 ± 89.8, 151.0 ± 87.9, and 151.8 ± 87.7 days, respectively (p = 0.095). Among persistent patients, additional therapy was prescribed for 36.2%, 41.7%, and 41.5% of patients, respectively. Among nonpersistent patients, 64.0%, 70.4%, and 69.2%, respectively, restarted the index therapy.

CONCLUSIONS

The largest proportion of first-time recipients of prostaglandin/beta-blocker FC products treated in UK primary care was prescribed latanoprost/timolol FC. Twelve-month persistence was similar (<40%) across the 3 FCs evaluated.

Balancing efficacy and tolerability of prostaglandin analogues and prostaglandin-timolol fixed combinations in primary open-angle glaucoma

BACKGROUND

Lowering intraocular pressure (IOP) is currently the only therapeutic approach that preserves visual function in primary open-angle glaucoma. In making treatment decisions for first- and second-line therapy, the clinician needs to provide an appropriate balance of efficacy and tolerability. Prostaglandin analogues (PGAs) are frequently used as first-line monotherapy, because of their efficacy and low risk of systemic side effects. Similarly, PGA-based fixed combinations are frequently used in patients who progress or fail to achieve the target IOP.

SCOPE

We have reviewed the literature on the management of primary open-angle glaucoma with PGAs, both as monotherapies and in fixed combinations.

FINDINGS

In the clinical trial and meta-analysis data identified, bimatoprost 0.03% seems to be associated with a greater overall ability to lower IOP compared with latanoprost, travoprost or tafluprost, at the cost of a slightly higher incidence of conjunctival hyperaemia. Studies indicate that patients' adherence to treatment is generally better with PGAs than with many other monotherapies. In patients requiring more than one IOP-lowering agent, fixed combination treatments may provide improved adherence and tolerability benefits compared with concomitant use of individual treatments. Bimatoprost/timolol fixed combination appears to be slightly more efficacious than latanoprost/timolol or travoprost/timolol, and tolerability differences between the fixed combinations appear to be slight, probably because the addition of timolol to the PGA component lessens the associated hyperaemia. Surveys on EU physician attitudes appear largely in line with these clinical data.

CONCLUSION

An appropriate balance between efficacy and tolerability ensures optimum IOP lowering and reduces the risk of non-adherence. PGAs largely fulfil this need as monotherapies and as components of combinations.

Antiglaucoma drugs: The role of preservative-free formulations

Hypersensitive reactions to eyedrops are a common finding in clinical practice and represent a frequent cause of discontinuation of the therapy. Moreover, experimental and clinical studies show that long term use of topical drugs may induce ocular surface changes causing discomfort and potentially negatively affecting the compliance to the treatment as well as the success rate of filtering procedures. The exact mechanism involved and the roles of the active compound and the preservatives in inducing such detrimental effects of ophthalmic solutions are unclear. During the last years several antiglaucoma agents have been marketed as either preservative-free or benzalkonium chloride-free formulations in an attempt to reduce the adverse effects related to preservatives. This paper summarizes the body of evidence from existing studies about preservatives in antiglaucoma eyedrops, focusing on the latest compounds commercially available. A systematic review of the literature was performed. Current research is focusing not only on the efficacy of the drugs but also on their tolerability. Based on the existing data, there is a rationale to support the use of benzalkonium-free solutions whenever possible, especially in patients suffering from concomitant ocular surface diseases, experiencing local side effects and in those expected to need multiple and prolonged topical treatments.

Role of fixed combinations in the management of open-angle glaucoma

The first-line option for lowering intraocular pressure (IOP) is a single hypotensive agent, but patients frequently require additional IOP-lowering agents to reach their target pressures. Disadvantages of this multi-therapy approach include washout effect, inconvenience and poor adherence. Fixed combinations (FCs) combine two or more hypotensive agents in a single bottle, providing a convenient once-daily therapy, which tends to improve adherence. FCs generally offer equivalent efficacy to concomitant use of the individual components, with equivalent or superior tolerability. Studies also show that FCs can be more cost effective than nonfixed combinations. In terms of optimizing IOP control, minimizing visual field deterioration, preventing visual disability and minimizing associated healthcare costs, FCs are an important component of glaucoma management.

Focusing on glaucoma progression and the clinical importance of progression rate measurement: a review

PURPOSE

This review aims to provide guidance in managing glaucoma patients more effectively. It focuses on the importance of detecting progression and measuring its rate within the management of primary open-angle glaucoma today. Recent findings strongly indicate that continued monitoring of visual fields (VFs) and reassessment of target intraocular pressures (IOPs) depending on VF progression rates are mandatory in the management of glaucoma.

METHODS

Data on glaucoma progression from older as well as most recent literature findings are summarized in this article. In addition, the article elaborates on the scientific content from a series of lectures given by experts in the field during several international symposia on 'rate of progression' in 2008.

RESULTS

This review summarizes key findings on the natural history of glaucoma and known factors for disease progression. It highlights the visual function changes observed as glaucoma progresses and discusses disease impact on patients' quality of life. Findings support the need to obtain information on rate of progression and its importance for clinical management. Practical ways to measure rate of progression are given by new software options to help measure major parameters. Finally, on the basis of a patient's individual rate of progression therapeutic options are assessed, such as maximum medical therapy with fixed combinations.

CONCLUSIONS

Estimating a patient's individual rate of VF progression by using newly developed analyses will be helpful to forecast the potential future development of the glaucoma. An individualized treatment approach then requires that in patients in whom the risk of becoming visually impaired or blind during their lifetime is higher, a more intensive medical IOP-lowering therapy such as fixed combinations can be considered as treatment option.

Tafluprost for the reduction of interocular pressure in open angle glaucoma and ocular hypertension

Tafluprost is an FP receptor antagonist that has been shown in clinical studies in Europe and Japan to be extremely useful in treating elevated intraocular pressure and glaucoma. The drug is well tolerated and appears to be at least equal in effectiveness and perhaps superior to other protanoids for routine use comparison to be superior to other treatments for the elevated IOP as the side effects and other related symptomology appear to be less, while maintaining a level of pressure control for prolonged periods.

Bimatoprost and bimatoprost/timolol fixed combination in patients with open-angle glaucoma and ocular hypertension

PURPOSE

To investigate the intraocular pressure (IOP) lowering effect of bimatoprost (BIM) 0.03% and the potential additional effect of the BIM 0.03%/timolol 0.5% fixed combination (BTFC) in eyes with ocular hypertension, primary open-angle glaucoma, or exfoliation glaucoma.

METHODS

Following an appropriate washout period that varied with previous medication, participants with ocular hypertension, primary open-angle glaucoma, or exfoliation glaucoma were treated with evening-dosed BIM for 5 weeks. They were then given evening-dosed BTFC for another 5 weeks. One randomly selected eye was evaluated. Goldmann applanation tonometry was performed by the same investigator at 8 a.m., 12 noon, 4 p.m., and 8 p.m. at baseline and at the end of each treatment period.

RESULTS

Thirty-three participants completed the study. Three patients discontinued because of local adverse effects during the BIM treatment period. The mean diurnal IOP (mean ± SD) at baseline, on BIM, and on BTFC were 24.8 ± 5.4, 17.3 ± 3.5, and 14.9 ± 3.1 mmHg, respectively (repeated measures analysis of variance, P < 0.001 for all pairwise comparisons). The individual time-point IOP values showed similar significant reductions. The percentage of IOP reduction from baseline was 30.2% for BIM and 39.9% for the BTFC. The mean ± SD diurnal fluctuation at baseline was 6.8 ± 3.2 mmHg, which decreased to 4.0 ± 3.1 and 2.9 ± 1.4 mmHg on BIM and BTFC, respectively (P < 0.05 for both treatments versus baseline).

CONCLUSIONS

Both BIM 0.03% and the BTFC were effective in lowering IOP in eyes with ocular hypertension and open-angle glaucoma. However, the fixed combination provided an additional statistically significant reduction in IOP compared with BIM 0.03%.

Twelve-month, randomized, controlled trial of bimatoprost 0.01%, 0.0125%, and 0.03% in patients with glaucoma or ocular hypertension

PURPOSE

To evaluate the intraocular pressure (IOP)-lowering efficacy and safety of ophthalmic formulations of bimatoprost 0.01% and 0.0125% compared with bimatoprost 0.03%.

DESIGN

Prospective, randomized, double-masked, multicenter clinical trial.

METHODS

Patients with glaucoma or ocular hypertension were randomized to receive once-daily bimatoprost 0.01% (n = 186), bimatoprost 0.0125% (n = 188), or bimatoprost 0.03% (n = 187) for 12 months. The primary efficacy measure was IOP. Safety measures included adverse events and an objective assessment of conjunctival hyperemia.

RESULTS

Baseline mean IOPs were similar among treatment groups. Differences in mean IOP between the bimatoprost 0.01% or 0.0125% groups and the bimatoprost 0.03% group were less than 0.9 mm Hg throughout follow-up. Bimatoprost 0.01%, but not bimatoprost 0.0125%, was equivalent in efficacy to bimatoprost 0.03% based on predetermined criteria (limits of the 95% confidence interval of the between-group difference in mean IOP within +/- 1.5 mm Hg at all time points and within +/- 1 mm Hg at most time points). The overall incidence of treatment-related adverse events was reduced significantly in the bimatoprost 0.01% and bimatoprost 0.0125% groups compared with the bimatoprost 0.03% group (P < or = .034). The percentage of patients with a moderate to severe increase from the baseline macroscopic hyperemia score was: bimatoprost 0.01%, 3.2%; bimatoprost 0.0125%, 9.0%; bimatoprost 0.03%, 9.1% (P = .019 for bimatoprost 0.01% vs 0.03%).

CONCLUSIONS

Bimatoprost 0.01% was equivalent to bimatoprost 0.03% in lowering IOP throughout 12 months of treatment and demonstrated improved tolerability, including less frequent and severe conjunctival hyperemia. Bimatoprost 0.01% demonstrated a better benefit-to-risk ratio than bimatoprost 0.0125%.

Preservatives in eyedrops: the good, the bad and the ugly

There is a large body of evidence from experimental and clinical studies showing that the long-term use of topical drugs may induce ocular surface changes, causing ocular discomfort, tear film instability, conjunctival inflammation, subconjunctival fibrosis, epithelial apoptosis, corneal surface impairment, and the potential risk of failure for further glaucoma surgery. Subclinical inflammation has also been described in patients receiving antiglaucoma treatments for long periods of time. However, the mechanisms involved, i.e., allergic, toxic, or inflammatory, as well as the respective roles of the active compound and the preservative in inducing the toxic and/or proinflammatory effects of ophthalmic solutions, is still being debated. The most frequently used preservative, benzalkonium chloride (BAK), has consistently demonstrated its toxic effects in laboratory, experimental, and clinical studies. As a quaternary ammonium, this compound has been shown to cause tear film instability, loss of goblet cells, conjunctival squamous metaplasia and apoptosis, disruption of the corneal epithelium barrier, and damage to deeper ocular tissues. The mechanisms causing these effects have not been fully elucidated, although the involvement of immunoinflammatory reactions with the release of proinflammatory cytokines, apoptosis, oxidative stress, as well as direct interactions with the lipid components of the tear film and cell membranes have been well established. Preservative-induced adverse effects are therefore far from being restricted to only allergic reactions, and side effects are often very difficult to identify because they mostly occur in a delayed or poorly specific manner. Care should therefore be taken to avoid the long-term use of preservatives, otherwise a less toxic alternative to BAK should be developed, as this weakly allergenic but highly toxic compound exerts dose- and time-dependent effects. On the basis of all these experimental and clinical reports, it would be advisable to use benzalkonium-free solutions whenever possible, especially in patients with the greatest exposure to high doses or prolonged treatments, in those suffering from preexisting or concomitant ocular surface diseases, and those experiencing side effects related to the ocular surface. Indeed, mild symptoms should not be underestimated, neglected, or denied, because they may very well be the apparent manifestations of more severe, potentially threatening subclinical reactions that may later cause major concerns.

Mixed treatment comparison and meta-regression of the efficacy and safety of prostaglandin analogues and comparators for primary open-angle glaucoma and ocular hypertension

OBJECTIVES

Primary open-angle glaucoma (POAG) is a chronic condition characterised by optic neuropathy and vision loss. Elevated intraocular pressure (IOP) can damage the optic nerve and is a risk factor for glaucoma, thus treatment usually comprises topical hypotensives. This analysis aims to address methodological issues associated with the synthesis of glaucoma clinical trial data, given variations in study methodology and IOP measurement.

METHODS

Meta-regression was used to estimate how IOP varies over time for patients receiving treatment. Relative treatment effects were assessed using a random-effects mixed treatment comparison (MTC) in order to preserve randomisation and avoid selection bias. To produce clinically meaningful outputs, these analyses were combined to obtain the mean on-treatment IOP and the proportion of patients achieving different IOP targets at different time points. A further MTC estimated the probability of hyperaemia events.

RESULTS

The analysis showed that after 3 months' treatment, between 58 and 83% of patients will have a > or =20% reduction in IOP and 70-93% of patients will have an absolute IOP <20 mmHg. Latanoprost and bimatoprost were found to produce significantly lower on-treatment IOP compared with timolol (p < 0.05); the difference between latanoprost and bimatoprost was not significant. Travoprost produced a lower mean IOP compared with timolol (not significant). Latanoprost-timolol was found to produce significantly lower IOP than latanoprost alone or beta-blockers. The probability of hyperaemia-type events varied between treatments from 14.8 to 63.03%. Latanoprost had significantly lower odds of hyperaemia than travoprost, bimatoprost, travoprost-timolol, or bimatoprost-timolol.

CONCLUSION

This analysis suggests that latanoprost and bimatoprost produce a statistically significant reduction in IOP compared with timolol, but are associated with a higher risk of hyperaemia. Out of all the prostaglandins, latanoprost may achieve a good balance between tolerability and IOP efficacy. As with all forms of meta-analysis, the results are based on the assumption that the studies and intervention groupings are sufficiently similar to be compared.

Bimatoprost - a review

Bimatoprost is a synthetic prostamide analog that is efficacious in the treatment of open-angle glaucoma, ocular hypertension and other forms of glaucoma. It reduces intraocular pressure (IOP) by increasing uveoscleral and trabecular outflow. When used as a 0.03% topical preparation once daily, it demonstrates sustained lowering of IOP of 7 - 8 mmHg over a 24-h period. The drug has been found to be more effective than timolol. In some studies it has shown greater ability to lower IOP when compared with other prostaglandin analogs; whereas in others all three clinically used prostaglandin analogs were found to be equally effective. It shows good IOP reduction when used in combination with other glaucoma medications. A common side effect includes mild conjunctival hyperemia, which is generally reversible. Other side effects include periorbital pigmentation, discomfort, ocular surface hyperemia and skin changes. Pharmacoeconomic data indicate that bimatoprost is cost effective in the treatment of open-angle glaucoma.

[Is it possible to combine fixed therapeutic associations?]

The number of fixed associations to treat intraocular pressure has increased over the recent years, to improve patient's treatment adherence. They are generally considered as comparable to the same components administered separately with, in some cases, less side effects. It could thus be appealing to combine fixed associations to reduce these side effects and retain efficacy. However, almost all fixed associations contain timolol, a beta blocker, with a risk of an excessive beta blocking dose and related systemic adverse drug reactions. Several fixed-associations contain a prostaglandin analogue. Their combination would not have a superior efficacy to one fixed combination taken alone. Furthermore, an increased risk or incidence of adverse drug reactions would appear. Specific clinical studies are required before recommending their use in daily clinical practice.

Bimatoprost/timolol: a review of its use in glaucoma and ocular hypertension

Topically administered bimatoprost 0.03%/timolol 0.5% ophthalmic solution (bimatoprost/timolol: Ganfort) comprises the synthetic prostamide bimatoprost (structurally related to prostaglandin F2 alpha) and the beta-adrenergic receptor antagonist timolol. Bimatoprost/timolol (one drop administered in the affected eye[s] once daily in the morning or evening) is an effective and well tolerated fixed combination for lowering intra-ocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension (OHT), including individuals uncontrolled on monotherapy with a beta-adrenergic receptor antagonist or prostaglandin analogue/prostamide.

Efficacy, tolerability and safety of the fixed combination of bimatoprost 0.03% and timolol 0.5% in a broad patient population: multicenter, open-label observational study

OBJECTIVE

To evaluate intraocular pressure (IOP)-lowering efficacy, tolerability, and safety of the fixed combination of bimatoprost 0.03% and timolol 0.5% (Ganfort) among German patients.

METHODS

Multicenter, observational, open-label study of patients with primary open angle glaucoma or ocular hypertension (n = 606). As determined by participating physicians, patients had insufficient IOP control and required a medication change. They were switched to once-daily fixed-combination bimatoprost/timolol with no wash-out period. IOP was recorded at treated baseline, 4-6 weeks and 12 weeks after switching. Tolerability was measured using a 4-step scale (excellent, good, moderate, poor) and all adverse events were recorded.

RESULTS

A total of 405 patients switched from monotherapy, 97 switched from other fixed combinations, and 104 switched from non-fixed combinations. Among all patients, 32.5% had used prostaglandin analog (PGA) monotherapy, 8.7% had been using a fixed combination that included a PGA, and 6.9% had been using an adjunctive combination of a PGA and a beta-blocker. Mean treated baseline IOP (+/-SD) for all patients was 20.7 +/- 3.5 mmHg. Overall, changing medication to fixed-combination bimatoprost/timolol lowered IOP to 16.6 +/- 2.7 mmHg (p < 0.001 vs. baseline) after 4-6 weeks and to 16.1 +/- 2.6 mmHg (p < 0.001) after 12 weeks; reductions of 19.8% and 22.2%, respectively. Combined bimatoprost/timolol provided an additional IOP reduction versus baseline in most subgroups based on prior treatment. At week 12, patients who had previously used a beta-blocker achieved an additional 25.8% decrease from baseline and IOP was reduced by 22.6% in former PGA monotherapy patients. At week 12, 84.6% of all eyes reached a target pressure less than or equal to 18 mmHg. Tolerability of bimatoprost/timolol was rated excellent or good by the physicians for 98.7% of patients and by 96.7% of the patients themselves. Few adverse events occurred during the treatment period.

CONCLUSIONS

Although this study was limited by its observational design, our results show that the fixed combination of bimatoprost 0.03%/timolol 0.5% was effective, well tolerated, and safe in a broad patient population.

Observational study results in glaucoma patients undergoing a regimen replacement to fixed combination travoprost 0.004%/timolol 0.5% in Germany

With the launch of the fixed combination of travoprost 0.004%/timolol 0.5% (trav/tim) in Germany in May 2006, a noninterventional observational study designed as an open-label, multicenter, 6-week trial was initiated in order to evaluate the efficacy and tolerability of this new drug combination in glaucoma patients. Participants were grouped into categories according to previous drug regimens: those on timolol monotherapy; those on prostaglandin analog (PGA) monotherapy; those on concomitant therapy with a PGA and timolol; and those on fixed combinations. Trav/tim was well accepted by the patients, with 87.9% judging the tolerability of the therapy as good, very good, or excellent. Analysis of intraocular pressure (IOP) measurements showed statistically significant IOP decreases in all four categories examined in our study after regimen substitution with fixed-combination trav/tim. Fixed-combination prostaglandin analog/beta-blocker formulations are an attractive therapeutic option due to their strong IOP-lowering efficacy with once-daily dosing. In this study, glaucoma patients who underwent a regimen modification to fixed-combination trav/tim showed further reductions in IOP, irrespective of which selected monoor multiple therapies had been used previously.

Reporting of noninferiority and equivalence randomized trials for major prostaglandins: a systematic survey of the ophthalmology literature

BACKGROUND

Standards for reporting clinical trials have improved the transparency of patient-important research. The Consolidated Standards of Reporting Trials (CONSORT) published an extension to address noninferiority and equivalence trials. We aimed to determine the reporting quality of prostaglandin noninferiority and equivalence trials in the treatment of glaucoma.

METHODS

We searched, independently and in duplicate, 6 electronic databases for eligible trials evaluating prostaglandins. We abstracted data on reporting of methodological criteria, including reporting of per-protocol [PP] and intention-to-treat [ITT] analysis, sample size estimation with margins, type of statistical analysis conducted, efficacy summaries, and use of hyperemia measures.

RESULTS

Trials involving the four major prostaglandin groups (latanoprost, travoprost, bimatoprost, unoprostone) were analyzed. We included 36 noninferiority and 11 equivalence trials. Seventeen out of the included 47 trials (36%, 95% Confidence Intervals [CI]: 24-51) were crossover designs. Only 3 studies (6%, 95% CI: 2-17) reported a presented results of both ITT and PP populations. Twelve studies (26%, 95% CI: 15-39) presented only ITT results but mentioned that PP population had similar results. Thirteen trials (28%, 95% CI: 17-42) presented only PP results with no mention of ITT population results while 17 studies (36%, 95% CI: 24-51) presented only ITT results with no mention of PP population results. Thirty-four (72%, 95% CI: 58-83) of studies adequately described their margin of noninferiority/equivalence. Sequence generation was reported in 22/47 trials (47%, 95% CI: 33-61). Allocation concealment was reported in only 10/47 (21%, 95% CI: 12-35) of the trials. Thirty-five studies (74%, 95% CI: 60-85) employed masking of at least two groups, 4/47 (9%, 95% CI: 3-20) masked only patients and 8/47 (17%, 95% CI: 9-30) were open label studies. Eight (17%, 95% CI: 9-30) of the 47 trials employed a combined test of noninferiority and superiority. We also found 6 differing methods of evaluating hyperemia.

CONCLUSION

The quality of reporting noninferiority/equivalency trials in the field of glaucoma is markedly heterogeneous. The adoption of the extended CONSORT statement by journals will potentially improve the transparency of this field.

Bimatoprost/timolol fixed combination: a 3-month double-masked, randomized parallel comparison to its individual components in patients with glaucoma or ocular hypertension

PURPOSE

To evaluate the safety and efficacy of a fixed combination (FC) of bimatoprost (BIM) and timolol (TIM) compared with each of the active components for 3 months.

PATIENTS AND METHODS

Two double-masked, randomized, multicenter parallel studies of FC (once-daily, mornings), BIM (once-daily, evenings), or TIM (twice-daily) were conducted in 1061 patients with glaucoma or ocular hypertension.

RESULTS

Mean diurnal decreases from baseline intraocular pressure (IOP) at month 3 were 8.1, 7.9, and 6.4 mm Hg for the FC, BIM, and TIM groups, respectively. The proportion of patients with a mean diurnal percent reduction from baseline in IOP of more than 20% across all visits was 81.8% (436/533), 72.1% (191/265), and 49.8% (131/263) for the FC, BIM, and TIM groups, respectively (P<0.001 for FC vs. BIM and FC vs. TIM). The proportion of patients achieving an IOP of less than 18 mm Hg at all time points was 39.2% (209/533), 28.7% (76/265), and 12.2% (32/263) for the FC, BIM, and TIM groups, respectively (P=0.003 for FC vs. BIM, and P<0.001 for FC vs. TIM). The most commonly reported treatment-related adverse event was conjunctival hyperemia, with the greatest incidence in BIM (38.5%, 102/265), followed by FC (22.7%, 121/533, P<0.0001 vs. BIM) and TIM (6.8%, 18/263; P<0.001 vs. FC).

CONCLUSIONS

FC was statistically significantly more effective than BIM or TIM for most comparisons, and safer than BIM with respect to common ocular adverse events. FC represents a convenient, therapeutic advantage over separate bottles.

Efficacy and safety of bimatoprost/timolol fixed combination in the treatment of glaucoma or ocular hypertension

When a single medication does not adequately control intraocular pressure, additional intraocular hypotensive agents are often added to the therapeutic regime. However, regimen complexity has been associated with reduced patient compliance. Treatment with a fixed combination may, therefore, increase compliance as a result of simplifying the dosage regimen. Bimatoprost/timolol fixed combination (BTFC) combines two clinically effective agents that decrease elevated intraocular pressure by independent mechanisms. In two clinical studies, BTFC was more effective than its individual components. Furthermore, in a non-inferiority study BTFC has been shown to be as effective as the association of its individual components. BTFC was clinically effective and generally well tolerated, with no unexpected adverse reactions reported for the BTFC compared with those reported for bimatoprost or timolol monotherapies.

Primary open angle glaucoma: an overview on medical therapy

The purpose of this review is to discuss the topics relevant to the use of intraocular pressure-lowering strategies, which remains the first line in the management of glaucoma. Estimates of blindness from glaucoma and identification of risk factors remain of interest for all ophthalmologists. New functional tests offer promise for better detection and more accurate diagnosis of glaucoma. We finally discuss the impact of various glaucoma therapies, the principles of monotherapy and fixed combinations, which offer benefits of convenience, cost, and safety.

Medical interventions for primary open angle glaucoma and ocular hypertension

BACKGROUND

Primary open angle glaucoma (POAG) is a progressive optic neuropathy with an elevated intraocular pressure (IOP), where the optic nerve head becomes pathologically excavated and the visual field (VF) is characteristically altered. Ocular hypertension (OHT) is a condition with elevated IOP but without discernible pathology of the optic nerve head or the VF. It is a major risk factor for development of POAG.

OBJECTIVES

To assess and compare the effectiveness of topical pharmacological treatment for POAG or OHT to prevent progression or onset of glaucomatous optic neuropathy.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE and EMBASE in May 2007. We searched the bibliographies of identified articles and contacted experts, investigators and pharmaceutical companies for additional published and unpublished studies.

SELECTION CRITERIA

Randomised controlled trials comparing topical pharmacological treatment to placebo, no treatment or other treatment for specified endpoints which included people with POAG or OHT, and with duration of treatment of at least one year.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed trial quality. Where appropriate, we summarised data using Peto odds ratio and mean difference after testing for heterogeneity between studies.

MAIN RESULTS

We included 26 trials, which randomised 4979 participants, in this review. Meta-analysis of 10 trials clearly demonstrated reduction of onset of VF defects in treated OHT (OR 0.62, 95% CI 0.47 to 0.81). No single drug showed a significant VF protection compared to placebo or untreated controls. We did identify some border line evidence for a positive influence of treatment on VF prognosis (OR 0.67, 95% CI 0.45 to 1.00) for the beta-blockers .

AUTHORS' CONCLUSIONS

The results of this review support the current practice of IOP lowering treatment of OHT. A visual field protective effect has been clearly demonstrated for medical IOP lowering treatment. Positive but weak evidence for a beneficial effect of the class of beta-blockers has been shown. Direct comparisons of prostaglandins or brimonidine to placebo are not available and the comparison of dorzolamide to placebo failed to demonstrate a protective effect. However, absence of data or failure to prove effectiveness should not be interpreted as proof of absence of any effect. The decision to treat a patient or not, as well as the decision regarding the drug with which to start treatment, should remain individualised, taking in to account the amount of damage, the level of IOP, age and other patient characteristics.

A comparison of the safety and intraocular pressure lowering of bimatoprost/timolol fixed combination versus latanoprost/timolol fixed combination in patients with open-angle glaucoma

PURPOSE

To compare the efficacy and tolerability of a once daily evening dose of the latanoprost/timolol fixed combination (LTFC) with that of a once-daily evening dose of the bimatoprost/timolol fixed combination (BTFC) in patients with open-angle glaucoma with elevated intraocular pressure (IOP) insufficiently responsive to monotherapy with prostaglandin analogues/prostamides.

DESIGN

Prospective, randomized, evaluator masked, single-center study.

PARTICIPANTS

36 patients with a diagnosis of open-angle glaucoma, with or without pseudoexfoliation, and inadequate control of IOP, insufficiently responsive to monotherapy with prostaglandin analogues/prostamides.

MAIN OUTCOME MEASURE

The primary end-points were the change in IOP at 9:00 am from baseline to week 4, and the difference between treatment groups in the mean diurnal IOP reduction from baseline to week 4.

RESULTS

BTFC provided significantly greater mean diurnal IOP reduction [mean (standard deviation)] 2.8 (0.9) mmHg, compared with LTFC 2.1 (0.6) mmHg, p = 0.0214. Both treatments significantly reduced the IOP from baseline at each IOP time-point measured, p < 0.0001, and for the mean diurnal IOP; p = 0.0049 for the LTFC, and p < 0.0001 for the BTFC. There were no significant differences in average hyperemia scores among groups, 1.25 (0.5) vs. 1.62 (0.69), p = 0.3835, for the LTFC and the BTFC, respectively.

CONCLUSIONS

The results of this study showed a significantly higher IOP-lowering effect of a once-daily evening dose of the BTFC compared to that of a once-daily evening administration of the LTFC.