Evolution of the treatment paradigm for maximum medical therapy in glaucoma

ABSTRACT

Introduction: Glaucoma therapy is typically started with a single drug that is considered most effective for IOP control and is relatively safe. Several classes of agents are available, including prostaglandin analogs (PGAs), β-blockers, carbonic anhydrase inhibitors (CAIs), cholinergic agonists, and α₂-agonists. Most patients will require combined therapy to achieve predetermined target intraocular pressure (IOP), which can be difficult to sustain over time. Currently, maximum medical therapy (MMT) in glaucoma refers to ≤3 classes of medications combined to substantially lower IOP. MMT can be achieved using multiple single agents, double, or triple fixed-dose combinations.

Areas covered: Several randomized controlled clinical trials demonstrated that 3-drug combination regimens are superior to 2-drug regimens for lowering 24-hour IOP, which may prevent glaucoma progression. However, long-term clinical evidence with 3- or 4-drug MMT regimens is scarce.

Expert commentary: The next logical step in evolution of effective MMT may be the use of 4 classes of medications, adding triple fixed-combination to single agent or combining fixed-dose combinations of CAI plus α₂-agonist and fixed-dose β-blocker plus PGA. Availability of novel fixed-dose combinations may optimize efficacy, tolerability, adherence, and improve long-term outcomes. Further controlled evidence is required to accurately delineate the value of current and future MMT regimens.

KEYWORDS:

• Glaucoma
• combination
• fixed dose
• intraocular pressure
• maximum medical therapy

Acknowledgments

Medical writing support was provided by Catherine DeBrosse, PhD, of Complete Healthcare Communications, LLC, North Wales, PA, and was funded by Novartis.

Declaration of interest

V P Costa has received honoraria, travel and research support from: Novartis, Allergan, Pfizer, União Quimica, Alcon. A G Konstas has received honoraria and travel support from Allergan, Mundipharma, Novartis, Santen, Thea, Vianex MSD; and research support from Allergan, Novartis, Omni Vision, Pharmathen, Santen. Medical writing support, provided by Catherine DeBrosse, PhD, of Complete Healthcare Communications, LLC, North Wales, PA, was utilized in the production of this manuscript and funded by Novartis. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Financial and competing interests disclosure

VPC: Honoraria, travel and research support: Novartis, Allergan, Pfizer, União Quimica, Alcon.

AK: Honoraria and travel support: Allergan, Mundipharma, Novartis, Santen, Thea, Vianex MSD; Research support: Allergan, Novartis, Omni Vision, Pharmathen, Santen.

TA: Advisor/consultant for Alcon Laboratories Inc, Allergan, Bausch & Lomb, Merck & Co Inc and Quark; grant support from Alcon Laboratories, Allergan, Aquesys, Carl Zeiss Meditec, Ellex, Ocular Therapeutics, and Santen Inc; lecture fees from Alcon Laboratories Inc, Allergan, Carl Zeiss Meditec, Ellex, Pfizer Inc., and Santen Inc.

Additional information

Funding

This work was supported by Novartis. Novartis contributed to the writing, review, and approval of the manuscript.