Page 48 - 21st Century Perspective - Glaucoma Supplement

Therapeutic Intervention

The most critical decision regarding therapeutic intervention is based on a two-pronged question:
Does the patient merit initiation of therapy, and second, what is the overall best medication(s) to
achieve target IOP range? Equally competent glaucoma doctors will vary substantially in both
aspects, exemplifying how medical care is often more art than science.

Depending on numerous factors, we consider the following approach: Begin with Vyzulta, a
traditional prostaglandin or a beta-blocker. Based on the current literature, if Vyzulta does not
achieve target IOP range, then it is doubtful that another prostaglandin drug option would be helpful.
Thus, if Vyzulta alone does not achieve target range, then we would add a nonselective
beta-blocker, such as generic timolol, administered once daily shortly after awakening.

If this same patient were to have clinically significant asthma, then we could consider adding
Rhopressa, primarily because of its once-daily administration. More common adjunctive drug options
would be generic 0.2% brimonidine, but because its IOP reduction falls to trough after about 8 hours

and does little or nothing during the sleep cycle, we would prescribe this drop to be used shortly after
awaking, and then the patient would use a second drop about 8 hours later. Although this approach
may be more effective than using Rhopressa (and this has not yet been borne out in rigorous
scientific studies), we are concerned about patient compliance with twice-daily therapy, as opposed
to once-daily therapy; this is certainly a prime consideration in managing patient dosing schedules.

Although topical carbonic anhydrase inhibitors do exert some reduction in IOP during the sleep
cycle, these medicines only reduce IOP by about 15% during the diurnal cycle, so we generally turn
to these as a last resort.

We rarely, if ever, recommend adding or switching to any combination drug, unless we have
performed a monocular therapeutic trial of each individual component to ensure that each drug is
providing a meaningful reduction in IOP and is truly needed. Then, and only then, can a combination
drug be intelligently and responsibly prescribed. Furthermore, and perhaps most importantly, it may

well be that one of the ingredient drugs in a combination drug could achieve target IOP range alone.
This must be determined before encumbering the patient with a more expensive combination drug.

Although we have traditionally used brimonidine or a topical carbonic anhydrase inhibitor, such as
dorzolamide solution or brinzolamide suspension, as second-line adjunctive drugs, we may begin
using Rhopressa in this capacity because of its once-daily administration. Until we have had ample

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