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Factors to Consider in Choosing Anti-Inflammatory Therapies for Dry Eye Disease


Experts discuss key factors to consider when using anti-inflammatory agents to treat dry eye disease (DED).


Bill B. Trattler, MD: We all realize, I think all of us, enjoy being able to use lifitegrast or Xiidra. And I'll ask Dr Brimer, you know, how do you decide? So, your patients come in, and you know, there's a cost to using medications, you obviously don't want to over medicate. How do you decide when to use lifitegrast versus cyclosporine, when you're going to add one or the other. What is the key [difference]? How do you decide between the two?

Crystal Brimer, OD: I feel like that's such a biased answer I'm going to give you. You know what I mean? In my clinic I have my favorite, I have my tear. I feel like absorption is important. You see all the newer molecules coming out with smaller size molecules and ways to protect it to get through the aqueous, so that it absorbs in the tissue better. But ultimately, I think a large factor is going to be patient tolerability. And I had a patient today, and I hardly ever do this, but I broke down and did it, I gave them samples of each because everything I've ever given, it was like, "No, no, no, no." And I said, "Listen, take five days with this. Take five days that call me back." Because I just don't expect a difference in how you feel. I just want to know what you can tolerate. So, at this point, I'm grateful to have options because none of these three, and even the ones to come are going to be perfect for every patient. And yes, we care about efficacy, and we want to get the most efficacy as quickly as we possibly can. But if they're not compliant, we're not going to get anything. And so, everybody is going to have a different response on what side effects they have, and what side effects they can tolerate. So, does it burn, does it give blurred vision? Is there a bad taste? And so that's one of the factors. One of the factors is cost. And I no longer can predict anything when it comes to that. But I do know that a couple of the companies have patient assist programs and I appreciate that, when they're able to come to the table and help my patients that can't afford it.

Bill B. Trattler, MD: Those are great comments and I agree. Any challenges? And I'll just briefly ask Dr. Nichols and then Dr. Matossian for this particular question, how do you decide between the two, because there are two good options. They both have really nice effects. But just curious, let’s go with Dr. Nichols, like how you kind of figure out which to use first.

Kelly K. Nichols, OD, MPH, PhD: We're in a teaching institution, so we keep that in mind as well. I mean, you know, we allow for our students to select which [treatment] they're going to try on a patient so that they can experience that while they're in school. And so, I used to have a preference and now I just sort of like to see where it goes with overseeing patients. Because [in reference to] the cost issue, we have a clientele at the school which isn't necessarily well off. And so, the patient assistance programs are good. Medicaid reimbursement for some of them are really helpful for patients. And certainly, now there's generic, which can be helpful, with cyclosporine. So, I do think that there are some options to be thinking about that, that I would hate to say, you know, yeah, I think about cost, because you never know what a patient is willing to pay for and what they're not. But yet giving them good options is critical and allowing them to try and see what side effect profile they have is also important because they have to stay on it in order to see an effect.

Bill B. Trattler, MD: Right. Great. Great points. Dr. Matossian, your thoughts on the two options?

Cynthia Matossian, MD, FACS: You know, I wish I could say we were in control of what drug our patients received. Just because we are prescribing it does not mean that that is the medication the patient is ending up with. Unfortunately, many switch outs happen at the level of the pharmacy because of the insurance program that the patient has. Maybe because of the amount of co-pay difference. So, there are so many different factors that go into how a patient ends up with a particular drug that I can no longer predict, if I write for A, do they get B, do they actually get A, or is it switched out? So, I'm happy if they end up with an immunomodulator, when warranted.

Bill B. Trattler, MD: That's a great answer, and it’s so true. I find the same thing. I'll write one and then I hear from my tech, "oh, sorry. That one wasn't the first time on there are lists of drugs and you have to go to this one now, unless they had failed this one." You know, it’s kind of can be challenging times. But I guess the point is that we have these great options. Our patients do have options. If one doesn't work, they can switch to another, and vice versa.

Transcript is AI-generated and edited for clarity and readability.

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