Jill Taylor

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The Xal-Ease delivery system (Pfizer Ophthalmics) is a plastic, L-shaped mechanical device that houses a bottle of latanoprost on one end and sports an eyecup on the other. To use the device, the patient tilts the head back, positions the eyecup around the lid of the eye, and presses a button that causes the proper amount of medication to be dispensed. 

The device is currently offered to patients free of charge. 

Dr. Sonty said the cost of treatment is often driven higher by the inability of many patients to administer the proper dose to the eye, either through improper pressure on the bottle, improper placement of the drop, or because of physical infirmities preventing them from steady application. 

To determine the effectiveness and patient reception of the device, Dr. Sonty and his colleagues provided 54 patients with glaucoma who were taking latanoprost with their own dispensers. Measurements were taken via a questionnaire that gathered information regarding comorbid conditions (arthritis and tremors); length of use; daily regular use; user-friendliness; drop delivery; reminding nature of the device; patient expectations/satisfaction; continued interest to use; reduction in refills/cost; recommendations to others; and opinion regarding development of similar devices for other medications. 

Among the 47 patients who responded, 89% of patients reported that the device exceeded their expectations, that they intended to continue to use it, and they would recommend the use of it to others. Similarly high numbers of patients reported satisfaction with device efficiency (87%) and the desire to have a similar device for administration of other medications (85%). Seventy one percent reported that they used the device on a daily basis. 

Among the drawbacks reported regarding the device included 58% of patients for whom the device did not serve as a reminder, and 23% who found it difficult to use, according to Dr. Sonty. 

Articles

Chicago-The expense of latanoprost (Xalatan, Pfizer Ophthalmics) treatment may be driven down with the use of a relatively new device that assists patients in proper administration of the eye drops, according to a research team led by Sriram Sonty, MD, FACS, clinical associate professor, University of Illinois, Chicago Eye Center.

Mechanical aid assists in administration of drug

-By implementing a different treatment regimen in each eye of patients with glaucoma, Alfred M. Solish, MD, found that not only does bimatoprost (Lumigan, Allergan) appear more effective than travoprost (Travatan, Alcon Laboratories) for reducing IOP, but also when given a choice of treatment, patients tend to prefer bimatoprost for that reason. Dr. Solish presented the results of that analysis in a poster at the American Glaucoma Society annual meeting. 

"Ever since I was first in practice, I have performed my own evaluations of new drugs," said Dr. Solish, in clinical practice with Southern California Glaucoma Consultants, Pasadena, CA. "Whenever a new drug comes out, I provide patients with samples and keep track of everyone I put on it. Once 40 or 50 patients have been treated, I'll pull the charts, take them home, and spend a few hours looking them over. It's labor-intensive because I do it all myself, but I've found some interesting things this way." 

Dr. Solish believes that this collection of data is important to his practice. He pointed out that the research performed for FDA approval purposes does not tell physicians how the drug is going to perform in a real-world clinical setting, primarily due to variables present in everyday patients that are excluded from a controlled environment. The idea for a prospective comparison of bimatoprost and travoprost came about because the two drugs were released on the same day, he continued. 

Between March 2001 and January 2002, Dr. Solish tracked patients with glaucoma or ocular hypertension and uncontrolled or poorly controlled IOP in both eyes who were given bimatoprost 0.03% or travoprost 0.004%. 

After treating approximately 300 patients, Dr. Solish found that not only were both agents potential substitutions for latanoprost (Xalatan, Pfizer Ophthalmics) in patients with suboptimal response to treatment, but compared with travoprost, bimatoprost lowered IOP a greater amount, and more often hit the predetermined target IOP. 

As part of this initial study, when both eyes had poorly controlled IOP, Dr Solish prescribed travoprost in one eye and bimatoprost in the other. Dr. Solish realized he had not employed randomization and began a new comparative study, randomly selecting the treatment to the eyes and collecting follow-up information while blinded to the treatment used for each eye. Latanoprost was also added to the bilateral comparison. 

Data from 55 patients were gathered over a period of 2 years and analyzed. The study population had a mean age of 67 years and had been living with glaucoma for a mean of 9.4 years. Diagnoses included chronic open-angle glaucoma (54.5%); ocular hypertension (25.5%); low-or normal-tension glaucoma (12.6%); pigmentary (7.3%); narrow-angle glaucoma (7.3%); chronic angle-closure glaucoma (3.6%); neovascular glaucoma (1.8%); and suspicion of glaucoma (1.8%). 

Among patients, 34.5% were already using two or more topical glaucoma medications, and 41.8% were already on monotherapy. Previous medications included latanoprost (58.2%); brimonidine/ adrenergic agonist (20%); dorzolamide/ timolol combination (18.2%); timolol/beta blocker (18.2%); dorzolamide/carbonic anhydrase inhibitor (9.1%), travoprost (1.8%); and carbachol (1.8%). Thirteen patients (23.8%) were on no prior treatment regimen. 

Patients entering treatment were randomly selected to receive bimatoprost in one eye and either travoprost or latanoprost in the opposite eye (only five  patients were treated with latanoprost, a number too few to reach significance upon analysis). Follow-up was scheduled 4 to 6 weeks after treatment initiation, at which point the change in IOP for each eye was measured, patients were debriefed and given a choice as to which medication they wished to continue with. 

As in the previous unrandomized study, Dr. Solish found that while both bimatoprost and travoprost significantly reduced IOP from baseline values (

 = 0.009, respectively), bimatoprost provided a greater IOP decrease than travoprost, although the difference was not statistically significant (

 = 0.230). He said that the study is limited in that only one IOP measurement was taken per patient and readily concedes that multiple measurements would be preferable if not for practical considerations regarding clinical practice management. 

Charleston, SC-By implementing a different treatment regimen in each eye of patients with glaucoma, Alfred M. Solish, MD, found that not only does bimatoprost (Lumigan, Allergan) appear more effective than travoprost (Travatan, Alcon Laboratories) for reducing IOP, but also when given a choice of treatment, patients tend to prefer bimatoprost for that reason. Dr. Solish presented the results of that analysis in a poster at the American Glaucoma Society annual meeting.

Patients prefer bimatoprost in bilateral comparison study

"Medications behave differently in an adjunct or add-on role than they do as primary therapy," said Robert J. Noecker, MD, vice chairman, University of Pittsburgh Medical Center (UPMC). "There's plenty of information for hypotensive agents used as monotherapy. In terms of combination therapies, there is good information available about how the older formulation of brimonidine 0.2% [Alphagan, Allergan] performs as an adjunct to latanoprost, but data are lacking regarding the newer purite-preserved formulations in this role." 

Patients included in the study had an IOP >18 mm Hg after 6 weeks or more of latanoprost monotherapy, and had no prior use of brimonidine 0.2% or brimonidine 0.15%. None had ocular surgery within the 3 months prior to study entry, nor functionally significant visual field loss or evidence of progressive visual field loss within the year. 

"This was a typical clinical situation where after monotherapy, you'd like to see the IOP lowered a bit more," Dr. Noecker said. "At entry, the average baseline latanoprost-treated pressure was 21.9 mm Hg. After about a month, patients received additive therapy with brimonidine 0.15%." 

Brimonidine 0.15% was administered twice daily, at 8 a.m. and 8 p.m. Measurements included IOP at peak drug effect (approximately 2 hours after the morning dose), and at trough drug effect (approximately 12 hours after the evening dose). Dr. Noecker and Earl found that the addition of brimonidine 0.15% to ongoing latanoprost therapy resulted in a significantly lower mean IOP at peak drug effect (

 <0.001). At 1 month, the mean IOP lowered to 16.1 mm Hg; at 2 months, the mean IOP was at 16.8 mm Hg. From the latanoprost-treated baseline at peak drug effect, brimonidine 0.15% provided an additional mean IOP reduction of 5.8 mm Hg (26%) after 1 month (

 <0.001), and an additional mean IOP reduction of 5.1 mm Hg (23%) at 2 months (

Further, significant reductions in IOP were also observed at trough drug effect (

 <0.002), with a mean IOP of 18.6 mm Hg at 1 month and 19.8 mm Hg at 2 months. 

From the latanoprost-treated baseline at trough drug effect, additional mean IOP reductions of 3.3 mm Hg (15%) at 1 month (

The observed tolerability of brimonidine 0.15% was also favorable. No serious adverse effects were reported, with the most common side effects being ocular allergy (n = 2, 5%) and foreign body sensation (n = 2, 5%). 

The researchers suggest that the demonstrated efficacy of brimonidine 0.15% as an adjunctive agent to latanoprost may be due to complementary mechanisms of action, with latanoprost and brimonidine both lowering IOP by increasing uveoscleral outflow and an additional action of brimonidine of decreasing aqueous production. 

Fort Lauderdale, FL-Brimonidine tartrate ophthalmic solution 0.15% (Alphagan P, Allergan) is an effective adjunctive therapy in patients with glaucoma using latanoprost (Xalatan, Pfizer Ophthalmics) who require additional IOP lowering, according to research reported at the Association for Research in Vision and Ophthalmology annual meeting.

Jill Taylor

Articles

Mechanical aid assists in administration of drug

Patients prefer bimatoprost in bilateral comparison study

Brimonidine 0.15% effective adjunctive therapy for open-angle glaucoma, ocular hypertension

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