Patient persistence with first-line antiglaucomatous monotherapy

Real-World Study on Patient Satisfaction and Tolerability After Switching to Preservative-Free Latanoprost

Purpose

Patient satisfaction is important in the treatment of glaucoma. Suboptimal compliance and impaired long-term outcome are a likely result of poor tolerability. The present multicentre, international, transverse, epidemiological survey was conducted to assess the satisfaction of patients who had received preservative-free latanoprost (PFL) for at least 3 months.

Patients and Methods

A total of 1872 patients from 6 European countries, treated with PFL for at least 3 months, were included in this survey. Prior to PFL treatment, patients were to be treatment naïve or currently treated for their glaucoma. During a single routine consultation, patients completed a questionnaire concerning global satisfaction and satisfaction based on tolerability.

Results

In total, 76.2% had been previously treated; 69.4% had received preserved and 6.8% preservative-free (PF) topical treatment. After 3 months of PFL treatment, a large majority of patients (95.3%) were satisfied or very satisfied with their PFL treatment and were, overall, significantly (p<0.0001) more satisfied with PFL than with their previous treatment; 4.2% were either unsatisfied or very unsatisfied. Overall, 97.3% of originally treatment-naïve patients were satisfied (50.1%) or very satisfied (47.2%) with their PFL. Ocular surface disease was diagnosed in 9.2% of patients (n=173) and was mainly mild (76.9%). Patient satisfaction with PFL was very high.

Conclusion

PFL may be considered a valuable first-choice treatment in glaucoma patients.

Better tolerance of preservative-free latanoprost compared to preserved glaucoma eye drops: the 12-month real-life FREE study

Background

Lack of efficacy due to bad compliance caused by intolerance issues is the main reason for a change to a better tolerated ocular treatment, such as using preservative-free (PF) eye drops.

Aim

To assess the efficacy and local tolerance after 12 months and patient satisfaction regarding local treatment tolerance and handling at inclusion and after 6 months of PF latanoprost compared to preserved glaucoma eye drops.

Methods

This was an international, prospective, and observational real-life study. Up to three visits, one at inclusion and two follow-up visits (one after 6 and one after 12 months) were planned. Efficacy, local tolerance, and patient satisfaction were the main evaluation criteria.

Results

Data from 721 patients were available for the statistical analysis. Overall, 64.8% (467/721) of patients switched treatment before inclusion: 62.2% in the preserved and 68.9% in the PF latanoprost group. IOP values were similar between PF latanoprost and preserved eye drops and remained stable at all visits. Ocular signs and symptoms improved after switching to PF latanoprost; the prevalence of conjunctival hyperemia was significantly lower (P=0.0015) at both follow-up visits. At follow-up visit 1, 49.5% of the patients who switched to PF latanoprost decreased or stopped the use of artificial tears. Satisfaction regarding tolerance in patients using PF latanoprost improved significantly after the switch from preserved eye drops to PF latanoprost (88.9% and 42.5%, respectively, P<0.0001).

Conclusion

This first real-life study showed that PF latanoprost was as efficacious but better tolerated than preserved eye drops over a sustained period of 12 months, while providing a significantly higher patient satisfaction and potentially allowing improvement in the patient’s daily life.

Switching to preservative-free latanoprost: impact on tolerability and patient satisfaction

Patient satisfaction with glaucoma treatment has been poorly studied to date. Because glaucoma is a chronic condition in which the therapeutic response is dependent on adherence to treatment, patient acceptability is an important factor in achieving satisfactory outcomes. This multicenter, international (Belgium, the Netherlands, and Spain), epidemiological convenience sample survey among patients commencing treatment with preservative-free latanoprost collected data on patient satisfaction with particular regard to tolerability. A total of 1,541 patients were recruited who were predominantly elderly (74% were over 60 years of age) and female (61%). Most of the patients had previously received preserved topical glaucoma medication (69%), 6.7% had previously received preservative-free medication, whereas 24% had not previously been treated for glaucoma. The great majority of patients (>95%) were satisfied with the preservative-free latanoprost treatment. Among the patients who had previously received preserved medication, 73% of patients found preservative-free latanoprost to be better tolerated and 89% found it at least as easy to use as their prior treatment. Patient satisfaction (determined by a 0-100 mm visual analog scale) was improved by 47% on a switch from preserved treatment to preservative-free latanoprost. Intraocular pressure was similar in patients who had previously received preserved (18.3 mmHg), preservative-free (17.8 mmHg) glaucoma medication or who were naïve to treatment (20.3 mmHg). Preservative-free latanoprost provided effective reduction of intraocular pressure with better tolerability and patient satisfaction than preserved glaucoma medication. This tolerability profile can be expected to improve adherence to treatment in glaucoma patients.

Comparison study of intraocular pressure reduction efficacy and safety between latanoprost and tafluprost in Japanese with normal-tension glaucoma

Purpose

To evaluate and compare the intraocular pressure (IOP) reduction efficacy and safety between the ophthalmic solutions 0.005% latanoprost (Lat) and 0.0015% tafluprost (Taf) in Japanese patients with normal-tension glaucoma (NTG).

Methods

In this randomized nonmasked study, we prospectively enrolled 30 Japanese NTG patients who had used Lat monotherapy for more than 4 weeks, and randomly divided them into the following two groups: 1) Lat-to-Taf group (LT group) and 2) Taf-to-Lat group (TL group). At the beginning of the study, both groups were switched from initial Lat to Lat or Taf for 12 weeks, and then switched over to the other drug (crossover) for 12 additional weeks. At 0, 4, 12, 16, and 24 weeks, we evaluated each patient’s IOP, conjunctival injection, and corneal epitheliopathy score, and at 0, 12, and 24 weeks, we evaluated their eyelash changes and pigmentation of the eyelids and irises.

Results

The mean IOP of the LT group (15 eyes) was 10.5, 10.6, and 11.1 mmHg, at 0, 12, and 24 weeks, respectively, whereas that of the TL group (15 eyes) was 11.7, 11.1, and 10.5 mmHg at 0, 12, and 24 weeks, respectively. No significant differences were found between the two groups and in the intragroup comparisons. Moreover, no significant differences were found between Lat and Taf in regard to the conjunctival injection score and corneal epitheliopathy score. Eyelash changes and eyelid and iris pigmentation were similar in both groups.

Conclusion

The findings of this study show that Lat and Taf have equivalent efficacy and safety in Japanese patients with NTG.

Latanoprost in the treatment of glaucoma

Prostaglandins are approved by the European Glaucoma Society guidelines as first-line treatment for glaucoma. This review focuses on latanoprost, an ester prodrug of prostaglandin (PG) F_2α, which was the first of the currently available topical PGF_2α analogs to be launched for glaucoma or ocular hypertension and which still accounts for the majority of prescriptions. It is better absorbed than the parent compound through the cornea, and peak concentration of the active drug is in the aqueous humor 1–2 hours after topical dosing (15–30 ng/mL). Metabolism occurs mainly in the liver. Latanoprost (0.005%) has been very well studied in clinical trials and meta-analyses that show it to be generally as effective as the other PG analogs (bimatoprost, travoprost, and tafluprost) and more effective than timolol, dorzolamide, and brimonidine. Latanoprost has good short- and long-term safety and tolerability profiles. In common with other prostaglandins, it lacks systemic effects, but can cause ocular adverse events such as conjunctival hyperemia, pigmentation of the iris, periocular skin or eyelashes, hypertrichosis, and ocular surface effects or irritation. Latanoprost is significantly better tolerated than either bimatoprost or travoprost. Patients treated with latanoprost have better compliance and persist with therapy longer than those that are given other drugs. An improved formulation of latanoprost without the preservative benzalkonium chloride has recently been developed. It is as effective as conventional latanoprost, has a lower incidence of hyperemia, and can be stored at room temperature. In conclusion, latanoprost has the best efficacy–tolerability ratio of the PG analogs available for glaucoma treatment, and has good compliance and persistence. These factors should be improved further by the recent development of preservative-free latanoprost.

Combination of brinzolamide and brimonidine for glaucoma and ocular hypertension: critical appraisal and patient focus

Glaucoma is one of the leading causes of blindness and is characterized by optic nerve damage that results in visual field loss. Elevated intraocular pressure (IOP) has been associated with glaucoma progression; thus, IOP-lowering medications are the standard of care for glaucoma. Guidelines suggest monotherapy with IOP-lowering agents such as β-blockers (eg, timolol), prostaglandin analogs, carbonic anhydrase inhibitors (eg, brinzolamide), and α2-receptor agonists (eg, brimonidine). However, monotherapy may provide insufficient IOP reduction in some patients, thereby necessitating the use of multiple IOP-lowering medications. Multidrug regimens may be complex, may increase the risk of preservative-related ocular symptoms, and may potentially reduce overall drug exposure as a consequence of drug washout during closely timed sequential administrations; these difficulties may reduce overall drug efficacy and decrease patient persistence and adherence with multidrug treatment regimens. Fixed-combination medications that provide two IOP-lowering therapies within a single solution are available and may overcome some of these challenges. However, all currently available fixed combinations combine timolol with another IOP-lowering agent, indicating that additional fixed-combination alternatives would be beneficial. To meet this demand, a novel fixed combination of brinzolamide 1% and brimonidine 0.2% (BBFC) has recently been developed. In two randomized, double-masked, multinational clinical trials, BBFC had greater IOP-lowering efficacy than brinzolamide or brimonidine monotherapy after 3 months of treatment in patients with open-angle glaucoma or ocular hypertension. In both studies, the overall safety profile of BBFC was consistent with that of brinzolamide and brimonidine. Comparative studies with BBFC versus other IOP-lowering monotherapy and fixed-combination medications are not available, but the IOP reductions observed with BBFC are similar to or greater than those reported in the literature for other glaucoma treatments; thus, BBFC provides an additional fixed-combination therapeutic option for patients who require further efficacious IOP reduction and improved convenience and tolerability versus concomitant administration of two separate medications.

Patient adherence and persistence with topical ocular hypotensive therapy in real-world practice: a comparison of bimatoprost 0.01% and travoprost Z 0.004% ophthalmic solutions

BACKGROUND

Effective control of intraocular pressure is predicated upon patient compliance with pharmacotherapy. We compared patient adherence and persistence with two new ocular hypotensive formulations, using real-world utilization data.

METHODS

This observational cohort study employed pharmacy claims data from the Source(®) Lx (Wolters Kluwer Pharma Solutions) database. Patients with an initial (index) prescription for topical bimatoprost 0.01% or travoprost Z (April to June 2011) and no claim for ophthalmic prostaglandin or prostamide analogs within the previous 18 months were identified. Treatment adherence was expressed as proportion of days covered with study medication during the first 365 days after the index prescription. Treatment persistence with study medication was assessed over the first 12 months using Kaplan-Meier survival analyses, allowing a maximum 30-day gap for prescription refill. Treatment status was determined monthly over this period.

RESULTS

A total of 12,985 patients were assessed for treatment adherence, and 10,470 for treatment persistence. Adherence was better with bimatoprost 0.01% than with travoprost Z (mean proportion of days covered 0.540 versus [vs] 0.486, P<0.001), and more patients showed high adherence (proportion of days covered >0.80) with bimatoprost 0.01% than travoprost Z (29.1% vs 22.3%, P<0.001). Continuous 12-month persistence was higher with bimatoprost 0.01% than with travoprost Z (29.5% vs 24.2%, P<0.001). At month 12, more patients were on treatment with bimatoprost 0.01% than travoprost Z (48.8% vs 45.7%, P<0.01). Similar findings were demonstrated in cohorts of ocular hypotensive treatment-naïve patients, branded latanoprost switchers, and older patients (age ≥65 years), and after inclusion of patient characteristics as covariates.

CONCLUSION

For patients with glaucoma or ocular hypertension, bimatoprost 0.01% offers compliance advantages over travoprost Z.

Preservative-free tafluprost in the treatment of naive patients with glaucoma and ocular hypertension

PURPOSE

The study reported here investigated the efficacy, tolerability, and safety of the preservative-free prostaglandin analog tafluprost 0.0015% in treatment-naive patients.

PATIENTS AND METHODS

Data were collected in two non-interventional, prospective, multicenter, observational, open-label studies of identical design that were conducted in Germany and the Czech Republic. All subjects received preservative-free tafluprost 0.0015% once daily. Intraocular pressure (IOP) levels were recorded for each eye at untreated baseline and 3 months after initiation of medical treatment. The primary outcome was change in mean IOP from baseline to month 3. In the primary open-angle glaucoma (POAG) and ocular hypertension (OH) patient subgroups, analyses were stratified by the level of baseline IOP: ≥20 to 23 mmHg versus ≥24 mmHg. In addition, responder rates and the achievement of pre-specified IOP levels at month 3 were evaluated. Local tolerance of preservative-free tafluprost was evaluated by the patients at final visit. Overall satisfaction with the medical treatment was evaluated by both patients and physicians. All adverse events were recorded.

RESULTS

A total of 579 treatment-naive patients with POAG (n = 349), OH (n = 105), normal tension glaucoma (n = 71), exfoliative glaucoma (n = 27), or other glaucomas (n = 27) were included in this observational study. Mean IOP level at baseline for all patients was 23.6 ± 4.0 mmHg. Mean IOP at month 3 was 16.8 ± 2.9 mmHg (-28.8% vs baseline). At month 3, significant reductions in mean IOP (P < 0.001) were seen in all patients and all subgroups. Preservative-free tafluprost lowered mean IOP significantly in patients with POAG and OH with IOP levels ≥ 20 to 23 mmHg from 21.9 ± 1.1 mmHg at baseline to 16.5 ± 2.2 mmHg, and in the subgroup with IOP levels ≥ 24 mmHg from 26.2 ± 2.4 mmHg to 17.9 ± 2.4 mmHg. In the subgroups of patients with POAG and OH, an IOP response ≥20%, ≥30%, and ≥40% was achieved by 83.4%, 44.1%, and 12.8%, respectively. Overall, patients with higher baseline IOP values showed a better response than patients with lower baseline IOP levels. Preservative-free tafluprost was well tolerated and safe. After 3 months, 97.9% of all patients remained on therapy.

CONCLUSION

In this real-world observational study, treatment with once-daily preservative-free tafluprost proved efficacious, well tolerated, and safe in treatment-naive patients.

In vitro and in vivo experimental studies on trabecular meshwork degeneration induced by benzalkonium chloride (an American Ophthalmological Society thesis)

PURPOSE

Long-term antiglaucomatous drug administration may cause irritation, dry eye, allergy, subconjunctival fibrosis, or increased risk of glaucoma surgery failure, potentially due to the preservative benzalkonium chloride (BAK), whose toxic, proinflammatory, and detergent effects have extensively been shown experimentally. We hypothesize that BAK also influences trabecular meshwork (TM) degeneration.

METHODS

Trabecular specimens were examined using immunohistology and reverse transcriptase-polymerase chain reaction. A trabecular cell line was stimulated by BAK and examined for apoptosis, oxidative stress, fractalkine and SDF-1 expression, and modulation of their receptors. An experimental model was developed with BAK subconjunctival injections to induce TM degeneration. Mass spectrometry (MS) imaging assessed BAK penetration after repeated instillations in rabbit eyes.

RESULTS

Trabecular specimens showed extremely low densities of trabecular cells and presence of cells expressing fractalkine and fractalkine receptor and their respective mRNAs. Benzalkonium in vitro induced apoptosis, oxidative stress, and fractalkine expression and inhibited the protective chemokine SDF-1 and Bcl2, also inducing a sustained intraocular pressure (IOP) increase, with dramatic apoptosis of trabecular cells and reduction of aqueous outflow. MS imaging showed that BAK could access the TM at measurable levels after repeated instillations.

CONCLUSION

BAK enhances all characteristics of TM degeneration typical of glaucoma-trabecular apoptosis, oxidative stress, induction of inflammatory chemokines-and causes degeneration in acute experimental conditions, potentially mimicking long-term accumulation. BAK was also shown to access the TM after repeated instillations. These findings support the hypothesis that antiglaucoma medications, through toxicity of their preservative, may cause further long-term trabecular degeneration and therefore enhance outflow resistance, reducing the impact of IOP-lowering agents.

Objective assessment of compliance and persistence among patients treated for glaucoma and ocular hypertension: a systematic review

PURPOSE

This study summarizes findings from objective assessments of compliance (or adherence) and persistence with ocular hypotensive agents in patients with glaucoma and ocular hypertension.

DESIGN

Systematic literature review.

METHODS

A PubMed and reference list search was conducted across publication years 1970-2010, using these terms and variants: "compliance," the equivalent term "adherence," and "persistence" in patients with these conditions and therapies. Summaries of selected studies were stratified by measurement method (electronic monitor, prescription fills review, medical chart review). Measures of central tendency across studies were calculated for commonly-reported compliance or persistence measures.

RESULTS

Fifty-eight articles met all inclusion/exclusion criteria: measurement of compliance-electronic monitoring (seven studies reported in 14 articles), measurement of compliance/ persistence-prescription records (36 studies in 38 articles), and measurement of persistence- medical chart review (six studies in six articles). From electronic monitoring, most therapy-experienced patients took medication consistently, but ≥20% met criteria for poor compliance. From prescription records, only 56% (range 37%-92%) of the days in the first therapy year could be dosed with the medication supply dispensed over this period. At 12 months from therapy start, only 31% (range 10%-68%) of new therapy users had not discontinued, and 40% (range 14%-67%) had not discontinued or changed the initial therapy. From medical chart review, only 67% (range 62%-78%) of patients remained persistent 12 months after starting therapy.

CONCLUSIONS

Evidence provided by this review suggests that poor compliance and persistence has been and remains a common problem for many glaucoma patients, and is especially problematic for patients new to therapy. The direction of empirical research should shift toward a greater emphasis on understanding of root causes and identification and testing of solutions for this problem.