Practical guidance for the use of cyclosporine ophthalmic solutions in the management of dry eye disease

Figures & data

Table 1 List of ocular formulations of cyclosporine A (CsA) marketed in different countries

Commercial name	Formulation	CsA dose	Company	Region (market since)
Restasis^a	Anionic oil-in-water emulsion (UD and MD)	0.5 mg/mL	Allergan	USA, Canada, and 33 other countries (2003)
Cequa^a	Micelle-based solution (UD)	0.9 mg/mL	Sun Pharmaceuticals Industries, Inc.	USA (2019^b)
Ikervis	Cationic oil-in-water emulsion (UD)	1.0 mg/mL	Santen Pharmaceuticals Co. Ltd.	Europe (2015)
Modusik-A Ofteno	Micelle-based solution (MD)	1.0 mg/mL	Laboratories Sophia	Mexico, Chile, Columbia, Ecuador, Peru (2003^b)
Lacrinmune	Oil-in-water emulsion (MD)	0.5 mg/mL	Baush & Loum, Inc.	Argentina (NA)
Papilock Mini	Micelle-based solution (UD)	1.0 mg/mL	Santen Pharmaceuticals Co. Ltd.	Japan (2005)
Ti Cyporin	Micelle-based solution (MD)	0.5 mg/mL	Taejoon Pharma Co. Ltd.	South Korea (2003)

Notes: ^aDrug approved by FDA. ^bEstimated date. Adapted from Lallemand F, Schmitt M, Bourges JL, Gurny R, Benita S, Garrigue JS. cyclosporine a delivery to the eye: a comprehensive review of academic and industrial efforts. Eur J Pharm Biopharm. 2017;117:14–28. doi:10.1016/j.ejpb.2017.03.006. Creative Commons license and disclaimer available from: http://creativecommons.org/licenses/by/4.0/legalcode http://creativecommons.org/licenses/by/4.0/legalcode.³⁷

Abbreviations: MD, multi-dose container; NA, not available; UD, unit-dose container.

Table 2 Step therapy management for dry eye disease

Step 1	Step 2	Step 3	Step 4
Patient education regarding DED condition, management and prognosis Review of risk factors and medications that worsen DED Local environment modifications Dietary modifications and oral supplementation of essential fatty acids Ocular lubricants Treatment of pre-existing conditions: MGD: Eyelid compression during the warm showers producing the drainage of meibomian glands Bacterial blepharitis: Topical antibiotic or antibiotic/steroid combination Demodex mite: tea tree oil	MGD: In-office expression of the meibomian glands Pulsed light treatments for drainage of meibomian glands Oral macrolide or tetracyclines Moisture chamber goggles overnight Punctal plugs Prescription options: Topical corticosteroids (short-term use) Topical non-glucocorticoid immunomodulatory drugs, such as cyclosporine A or lifitegrast (long-term use) Topical secretagogues	Oral secretagogues (pilocarpine or cevimeline) Autologous serum eye drops Contact lens therapy: Soft bandage lenses Scleral lenses	Surgical options: Amniotic membrane grafts Surgical punctal occlusion Salivary gland transplant Tarsorrhaphy

Note: Data from Jones et al.¹⁵

Abbreviations: DED, dry eye disease; MGD, meibomian gland dysfunction.

Figure 1 Dry eye disease (DED) management strategy. Data from Jones et al (2017).¹⁵

Lallemand F, Schmitt M, Bourges JL, Gurny R, Benita S, Garrigue JS. cyclosporine a delivery to the eye: a comprehensive review of academic and industrial efforts. Eur J Pharm Biopharm. 2017;117:14–28. doi:10.1016/j.ejpb.2017.03.006

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Jones L, Downie LE, Korb D, et al. TFOS DEWS II management and therapy report. Ocul Surf. 2017;15(3):575–628. doi:10.1016/j.jtos.2017.05.006

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