Switching patients from preserved prostaglandin-analog monotherapy to preservative-free tafluprost

Real-Life Study on the Efficacy and Tolerance of a Preservative-Free Surfactant-Free Latanoprost Eye Drop in Patients with Glaucoma

INTRODUCTION

The purpose of this study is to assess the real-life efficacy and tolerance of a new preservative-free, surfactant-free latanoprost (PFSF-LAT) formulation.

METHODS

Retrospective, multicentre, non-comparative, observational study in patients with ocular hypertension or open angle glaucoma, naïve or non-naïve to previous intraocular pressure (IOP)-lowering treatment, and treated for at least 3 months with the study eye drop. IOP for worse eye, ocular signs and symptoms, and concomitant use of artificial tears were collected at study drug initiation and at last visit under treatment. Reasons for discontinuing the study eye drop (if relevant) and investigators' satisfaction were also assessed.

RESULTS

In the per protocol population (103 eyes; 63 naïve, 39 switched, 1 not classified because of missing data), IOP decreased significantly (p < 0.001) from 21.6 ± 5.0 mmHg at baseline to 16.1 ± 3.5 mmHg at the end of the study (mean reduction of - 5.5 ± 4.6 mmHg; - 25.5%). IOP in naïve patients was significantly improved, with a mean reduction of 7.1 mmHg (- 30.7%), which was within expected latanoprost IOP-lowering effect. Interestingly, in previously treated patients, switching to PFSF-LAT also allowed for a further 2.9 mmHg decrease in IOP (p < 0.001). The incidence of ocular side effects at study initiation was significantly (p < 0.001) reduced from 31.1% to 11.3% in the overall population, and from 65.0% to 7.5% in switched patients. This included conjunctival hyperaemia and superficial punctate keratitis (from 42.5% to 2.5% and from 37.5% to 2.5% in switched patients, respectively). According to investigators, tolerance and efficacy of the study eye drop were satisfactory or very satisfactory in 98.1% and 83.2% of patients, respectively.

CONCLUSION

PFSF-LAT is an efficient treatment for patients with glaucoma with an improved tolerance profile. It can be considered as initial therapy in naïve patients or in patients with poor ocular tolerance to previous IOP-lowering eye drops.

[Three-component tear substitute as preoperative support in glaucoma surgery]

PURPOSE

This study investigates the effect of preoperative preparation with the three-component tear substitute Stillavit on the outcomes of glaucoma surgery in patients on long-term topical glaucoma therapy.

MATERIAL AND METHODS

The study included 63 patients (63 eyes) with glaucoma, among them 30 (30 eyes) were women and 33 (33 eyes) were men. Group 1 consisted of 33 patients (33 eyes) receiving long-term topical antihypertensive therapy with preservatives and tear substitute Stillavit 3 times a day for 1 month as preoperative preparation. Group 2 included 30 patients (30 eyes) receiving similar antihypertensive therapy who were not prescribed preoperative medications. All patients underwent a comprehensive ophthalmological examination and computer tomography of the filtering blebs (FB) on Visante system (Carl Zeiss Meditec, Germany) before surgery, as well as 1 week, 1, 3, and 6 months after surgery.

RESULTS

Mean intraocular pressure (IOP) elevation at 6 months postoperatively was significantly higher in the group that did not undergo preoperative preparation with a tear substitute, compared to the group of patients who received the tear substitute Stillavit preoperatively. According to anterior segment optical coherence tomography, a greater number of favorable diffuse FB were noted in the group that received the tear substitute Stillavit in preparation for surgery - 87.9%, while in group 2 (without preparation) - 66.7%. Odds ratio calculation between the two groups revealed that preoperative preparation with the tear substitute Stillavit reduced the odds of IOP elevation to 20 mm Hg or higher at 3 months postoperatively by more than 10 times.

CONCLUSION

The use of tear substitute Stillavit in preparation for anti-glaucoma surgery reduces the chances of IOP elevation in the early postoperative period by more than 10 times, which may indicate a reduction in the rate of FB scarring due to the beneficial effect of the drug's components on the precorneal tear film.

A Narrative Review of Ocular Surface Disease Related to Anti-Glaucomatous Medications

Topical anti-glaucomatous medications are still the most important measure to lower intraocular pressure. Large number of studies have confirmed that long-term use of anti-glaucomatous eye drops, especially containing benzalkonium chloride, a preservative, can cause or aggravate ocular surface injury. Ocular surface diseases damage the ocular microenvironmental health status, reduce the patients’ compliance with the treatment, and finally affect the treatment result. Therefore, the ocular surface management of patients with glaucoma is very important. This includes the selection of drugs that are better tolerated according to individual conditions, preservative-free formulations, drugs that protect against ocular surface disease, or selecting surgery and laser treatment, to prevent the damage to the ocular surface by topical anti-glaucomatous drugs.

Ocular Surface Changes After Switching from Other Prostaglandins to Tafluprost and Preservative-Free Tafluprost in Glaucoma Patients

Purpose

To study ocular surface disease (OSD) changes after switching from preserved prostaglandin analogues monotherapy to preserved tafluprost and preservative-free (PF) tafluprost in primary open-angle glaucoma patients.

Methods

Glaucoma patients treated with preserved prostaglandins (except tafluprost) monotherapy for at least 6 months, intraocular pressure (IOP) ≤22 mmHg, and diagnosed of OSD [≥1 criterion; tear break-up time (TBUT) ≤10 seconds, corneal fluorescein staining ≥grade 1] in both eyes were enrolled in a prospective, randomized, single-blinded study. All eligible patients were switched from preserved prostaglandin analogues monotherapy (latanoprost, bimatoprost, travoprost) to preserved tafluprost in one eye (group I) and PF-tafluprost in the other eye (group II) of the same patient by randomization. The symptoms of OSD were evaluated using the visual analogue scale, and lid inflammation, conjunctival hyperemia, TBUT, corneal fluorescein staining, and Schirmer I test were applied to assess the clinical signs. All parameters were evaluated before and then 6, 12, 24 weeks after switching the medications.

Results

Thirty patients (80% women; mean age: 61.2 ±11.5 years) were included. Baseline parameters were not different between the treatment groups. After switching therapies, TBUT was significantly increased in both groups (p = 0.002, p = 0.004, respectively); however, group II had better tear quality. Other symptoms and clinical signs of OSD were improved and IOP was controlled in both groups.

Conclusion

Treatment with PF-tafluprost improves TBUT better than preserved tafluprost, suggesting that PF-tafluprost should be especially beneficial for patients with pre-existing OSD. Less or no preservative anti-glaucoma eye drops can restore and enhance the ocular surface in glaucoma patients.

Management Of Glaucoma In Developing Countries: Challenges And Opportunities For Improvement

Glaucoma is the leading cause of blindness in the developed and developing world. Not only is the clinical impact of this disease considerable, but associated economic and humanistic burdens - affecting patients, caregivers, and society - are substantial. Since glaucoma is an age-related disorder and populations in many developing countries are aging at a faster pace than in the developed world, increasing attention is being focused on ways to ameliorate the burdens of illness. In this paper, we examine the burdens of glaucoma with particular focus on developing countries, discuss some of the challenges that exist in delivering optimal glaucoma management within budget constraints, and bring into perspective how we could improve current healthcare systems, leverage technology, and strike an appropriate balance between cost and quality of care, thereby offering considerations to payors and policymakers in these countries that may result in longer-term cost savings, while concurrently striving to achieve the WHO Vision on the prevention of blindness and visual impairment.

Preservative-Free Prostaglandin Analogs and Prostaglandin/Timolol Fixed Combinations in the Treatment of Glaucoma: Efficacy, Safety and Potential Advantages

Glaucoma therapy-related ocular surface disease (OSD) is a serious pathology with a broad spectrum of insidious clinical presentations and complex pathogenesis that undermines long-term glaucoma care. Preservatives, especially benzalkonium chloride (BAK), contained in topical intraocular pressure-lowering medications frequently cause or aggravate OSD in glaucoma. Management of these patients is challenging, and to date often empirical due to the scarcity of controlled long-term clinical trials. Most of the available data are extracted from case series and retrospective analysis. Preservative-free prostaglandins and prostaglandin/timolol fixed combinations are novel options developed to remove the harmful impact of preservatives, especially BAK, upon ocular tissues. Based on what is currently known on the value of preservative-free antiglaucoma therapies it is tempting to speculate how these new therapies may affect the future medical management of all glaucoma patients. This article provides a comprehensive and critical review of the current literature on preservative-free prostaglandins and preservative-free prostaglandin/timolol fixed combinations.

Comparison of Efficacy and Ocular Surface Disease Index Score between Bimatoprost, Latanoprost, Travoprost, and Tafluprost in Glaucoma Patients

Aim

The purpose of this study is to evaluate and compare the efficacy of 4 prostaglandin analogues (PGAs) and to determine the incidence of ocular surface disease in newly diagnosed, primary open-angle glaucoma (POAG) patients started on one of those 4 PGAs: bimatoprost (benzalkonium chloride, BAK, 0.3 mg/mL), latanoprost (BAK 0.2 mg/mL), travoprost (polyquad), and tafluprost (BAK-free).

Patients and Methods

In this single-center, open-label trial, 32 patients newly diagnosed with POAG were randomly started on one of the four PGAs. All patients underwent a complete ophthalmological exam at presentation and at 1, 3, and 6 months of follow-up. Dry eye disease (DED) was assessed using the original Ocular Surface Disease Index (OSDI) questionnaire, in order to evaluate the impact of the drops on the quality of life of patients.

Results

The mean age was 60.06 years ± 11.76. All four drugs equally and significantly reduced the intraocular pressure (IOP) with respect to the baseline IOP. There was a trend for a slightly greater reduction of IOP with bimatoprost, but the difference was not found to be statistically significant when compared to other PGAs. OSDI scores were significantly superior for travoprost (10.68 ± 5.73) compared to the other three drugs (p < 0.05). Latanoprost caused the most significant eyelash growth and iris discoloration. Conjunctival hyperemia and superficial keratitis occurrence were similar in the four groups.

Conclusion

All prostaglandin analogues equally and significantly reduce the IOP in patients with POAG. According to the results of the OSDI score, latanoprost seems to be the least tolerated among the four drugs.

Changes in Ocular Surface Characteristics after Switching from Benzalkonium Chloride-Preserved Latanoprost to Preservative-Free Tafluprost or Benzalkonium Chloride-Preserved Tafluprost

Purpose

The aim of the present study was to examine the effects of switching from Latanoprost ophthalmic solution containing a preservative to preservative-free Tafluprost ophthalmic solution or Tafluprost containing a preservative on ocular surfaces.

Materials and Methods

Forty patients (40 eyes) with glaucoma (mean age: 62.0 ± 10.9 years) using Latanoprost with preservative for six months or longer were assigned either to a Tafluprost-containing-preservative group (20 eyes) or preservative-free-Tafluprost group (20 eyes). The intraocular pressure, corneal epithelial barrier function (fluorescein uptake concentration with fluorophotometer FL-500), superficial punctate keratopathy (AD classification), and tear film breakup time (TBUT) were assessed before switching and at 12 weeks after switching.

Results

No significant differences in intraocular pressure were noted after switching in either group. Corneal epithelial barrier function was improved significantly after switching in both the Tafluprost-containing-preservative and the preservative-free-Tafluprost groups. There were no significant differences in AD scores after switching in the Tafluprost-containing-preservative group, but significant improvements were noted in the preservative-free-Tafluprost group. No significant differences in TBUT were noted in the Tafluprost-containing-preservative or preservative-free-Tafluprost groups after switching.

Conclusion

After switching from preservative Latanoprost to Tafluprost containing-preservative or preservative-free Tafluprost, corneal epithelial barrier function was improved while the intraocular pressure reduction was retained.

Preservative-free bimatoprost 0.03% in patients with primary open-angle glaucoma or ocular hypertension in clinical practice

BACKGROUND

Intraocular pressure (IOP)-lowering medications for primary open-angle glaucoma and ocular hypertension commonly contain preservatives that can cause ocular surface damage in many patients. The purpose of this study was to evaluate the efficacy and tolerability of, and compliance to, preservative-free (PF) bimatoprost 0.03% in patients with primary open-angle glaucoma or ocular hypertension (IOP ≥18 mmHg) in a clinical practice setting.

METHODS

This open-label study observed patients who were switched to PF bimatoprost 0.03% for medical reasons. IOP was measured at baseline and ~12 weeks later at the final visit, and the change in IOP was calculated. Tolerability and continuation of therapy were assessed at two follow-up visits.

RESULTS

A total of 1,830 patients were included in the study, and complete IOP data were available for 1,543 patients. Mean IOP was reduced by 23% from 21.64 mmHg to 16.59 mmHg (P<0.0001). In subgroup analyses, the mean IOP was significantly reduced compared with baseline, regardless of prior therapy, including those previously treated with PF monotherapy. A total of 85.7% of physicians reported the IOP-lowering efficacy of PF bimatoprost 0.03% to be as expected or better than expected. Adverse events (AEs) were experienced by 5.7% of patients, and there were no serious AEs reported. The most common AEs were eye irritation (1.7%) and hyperemia (1.4%). Physician-reported treatment compliance was reported as better than (48.7%) or equal to (43.6%) prior treatment in most patients. Most patients (82%) were expected to continue PF bimatoprost 0.03% after the end of the study.

CONCLUSION

This observational study showed that, in clinical practice, switching to PF bimatoprost 0.03% was associated with a significant IOP reduction from baseline. There was a low AE rate. PF bimatoprost 0.03% may, therefore, be an effective treatment option for patients who are intolerant of preservatives or have an inadequate response to prior IOP-lowering treatments.

Effect of 3 years of treatment with a dorzolamide/timolol (1%/0.5%) combination on intraocular pressure

Purpose

We aimed to evaluate the effect on the intraocular pressure (IOP) of a dorzolamide/timolol (1%/0.5%) fixed combination (DTFC) ophthalmic agent for 3 years.

Participants

A total of 19 consecutive patients who had previously been treated with mono-therapy or any combination of a beta-blocker, carbonic anhydrase inhibitor, or prostaglandin analog, for primary open-angle glaucoma (POAG) (n=5) or normal tension glaucoma (N=14) were enrolled.

Methods

Patients were switched to DTFC from their prior glaucoma therapy. The IOP was measured at intervals of 4–6 weeks for 3 years. Treatment failure was defined as an increase of IOP by ≥10% from baseline after switching to DTFC.

Results

The average IOP decreased significantly from 14.1±2.9 mmHg at baseline to 12.2±2.2, 11.8±2.4, 12.1±2.5, 11.6±1.8, and 12.1±2.7 mmHg at 3, 6, 12, 24, and 36 months, respectively, after switching therapy (all P<0.05). The mean percent decrease of IOP was 12.0%±13.0%, 14.5%±14.2%, 12.2%±18.7%, 16.0%±12.8%, and 12.8%±15.2% at 3, 6, 12, 24, and 36 months, respectively, after switching. Univariate or multivariate analysis revealed the percent decrease of IOP was associated with the type of glaucoma (POAG) at 3 and 12 months, and with the baseline IOP at 3, 12, 24, and 36 months. Kaplan–Meier analysis demonstrated that the percentage of patients who remained on treatment with DTFC was 94.7%, 94.7%, 84.2%, 78.9%, and 78.9% at 3, 6, 12, 24, and 36 months, respectively. Cox proportional hazards analysis showed that the type of glaucoma (POAG) was associated with an increased risk of failure to control the IOP.

Conclusion

The IOP-lowering effect of DTFC was demonstrated for 3 years in this study. The baseline IOP had an important influence on the reduction of IOP achieved by DTFC.

Effect of dorzolamide/timolol combination on the visual field in glaucoma

PURPOSE

To evaluate the effect of treatment for 3 years with a dorzolamide/timolol (1%/0.5%) fixed combination (DTFC) on visual field progression in patients with open-angle glaucoma.

PARTICIPANTS

A total of 14 consecutive patients were enrolled who had been previously treated with monotherapy or any combination of a beta blocker, carbonic anhydrase inhibitor, and/or prostaglandin analog for primary open-angle glaucoma (POAG; n=4) or normal-tension glaucoma (NTG; n=10).

METHODS

Patients were switched to DTFC from their prior glaucoma therapy. The IOP was measured at intervals of 4-6 weeks, and the visual fields were examined at least twice a year for 3 years. The annual change of mean deviation (MD slope) was used to quantify visual field loss.

RESULTS

The mean MD value was -5.9±5.0 dB at baseline; it was -5.6±4.8 dB at 12 months, -5.9±5.0 dB at 24 months, and -5.6±5.1 dB at 36 months after switching. The mean MD slope was -0.2±0.8 dB/year before switching and 0.3±1.3 dB/year from baseline to 1 year, -0.3±1.1 dB/year from 1-2 years, and 0.3±0.9 dB/year from 2-3 years after switching. The mean MD slope from baseline to 36 months was correlated with the IOP reduction rate at 36 months after switching. Visual field progression was associated with the IOP reduction rate at 12 months after switching.

CONCLUSION

Switching to DTFC from prior glaucoma therapy improved the MD slope for at least 3 years. Reduction of the IOP after switching to DTFC was effective for delaying visual field progression. Although our study was not nonrandomized and was small in scale, the findings suggest that DTFC might have a beneficial effect on the visual fields in patients with open-angle glaucoma.

Improvement in glaucoma patient quality of life by therapy switch to preservative-free timolol/dorzolamide fixed combination

PURPOSE

To assess a change in visual-related quality of life (QoL) in glaucoma patients after switching from preservative-containing medical therapy to preservative-free unit dose timolol/dorzolamide fixed combination (TDFC UD).

METHODS

Prospective, noninterventional, multicenter 8-week study. Primary outcome was a change in visual symptoms at week 8, as assessed by the Glaucoma Symptom Scale (GSS).

RESULTS

80 patients completed the study. There was a clinically significant increase in the scores of all GSS-related categories at week 8 when compared to baseline (GSS symptom week 8: +21.15 ± 37.9%, GSS function week 8: +10.3 ± 31.6%, both p < 0.001 vs. baseline). Comparison between patients taking only TDFC UD and patients taking TDFC UD plus concomitant medications did not detect differences in any GSS category (p > 0.50 in all comparisons).

CONCLUSIONS

Switching to TDFC UD significantly improved the self-reported QoL of glaucoma patients. This can be seen even in patients who are taking concomitant ocular treatments.

Tafluprost once daily for treatment of elevated intraocular pressure in patients with open-angle glaucoma

Glaucoma is a leading cause of visual loss worldwide. Current antiglaucoma therapy focuses on lowering intraocular pressure to a safe level. In recent years, prostaglandin analogs have become the first-line agents for treating open angle glaucoma. Tafluprost, which was first reported in 2003, is a novel prostaglandin analog, and has been shown to be a potent ocular hypotensive agent in a number of preclinical and clinical studies. Also, its unique preservative-free formulation helps to decrease preservative-associated ocular disorders and improve patient compliance. In this review, studies from 2003 to 2012 focusing on the structure, metabolism, efficacy, and safety of tafluprost are summarized. These studies suggested that application of tafluprost once daily is a safe and effective treatment for patients with open angle glaucoma.

Corneal epithelial toxicity of antiglaucoma formulations: in vitro study of repeated applications

Background

By using a biologically relevant and sensitive three-dimensional model of human corneal epithelium and multiple endpoint analysis, assessment of the potential for eye irritation and long-term compatibility of four registered ophthalmological preparations, ie, Timolabak^®, Timoptol^®, Nyogel^®, and Timogel^®, was performed. This approach enables classification of the potential for irritation, discriminating between mildly irritant and non-irritant ocular substances.

Methods

The exposure protocol included two time periods, ie, 24 hours (acute application) and 72 hours (repeated applications twice daily). This approach allows assessment of not only the acute reaction but also possible recovery, as well as mimicking the potential cumulative effects associated with long-term application. Using benzalkonium chloride (BAK) 0.01% as a positive control, the following parameters were quantified: cellular viability by MTT test, histological analysis by hematoxylin and eosin staining, passive release of interleukin-1α by enzyme-linked immunosorbent assay, and OCLN gene expression by quantitative real-time polymerase chain reaction.

Results

Cell viability was reduced to under the 50% cutoff value after acute exposure (24 hours) to BAK 0.01%, and after repeated application (72 hours) of Timoptol and Nyogel. Histological analysis after acute exposure showed signs of superficial damage with all formulations, and severe changes after repeated applications of Timoptol, BAK 0.01%, and Nyogel. Timolabak and Timogel did not significantly alter the morphology of the human corneal epithelial cells after the different exposure times. Interleukin-1α release was greater than that for the negative control (>20 pg/mL) and the positive control (BAK 0.01%), Nyogel, and Timoptol treatments and not different after treatment with Timolabak and Timogel. Expression of OCLN, a sign of epithelial barrier impairment, was only significantly upregulated at 24 hours by BAK 0.01%, suggesting a toxic reaction at the ocular surface. OCLN was also overexpressed after repeated application of Nyogel and Timogel.

Conclusion

Overall, the multiple endpoint analysis approach allows classification of these products according to decreasing order of irritation potential as follows: BAK 0.01%, Timoptol, Nyogel, Timogel, and Timolabak.

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.