Patient education key to cyclosporine therapy success

"Topical cyclosporine is a relatively new modality for a condition that we have had limited therapeutic options for in the past, and it has the potential to be of significant benefit," said Dr. Rapuano, co-director, Cornea Service, Wills Eye Hospital, Phil-adelphia, and professor of ophthalmology, Jefferson Medical College, Thomas Jefferson University, Philadelphia. "However, as with any medical treatment, achieving a good outcome depends in part on patients having appropriate expectations."

His discussion focuses on three issues-the rationale for and mechanism/onset of cyclosporine, treatment-related side effects, and cost.

"I explain to patients that dry eye is often related to low-grade inflammation that neither the patient nor the doctor can perceive," he said. "However, that inflammation damages the tear-producing cells. By decreasing the inflammation, cyclo-sporine can allow the cells to produce more tears that are better quality."

Patients are also forewarned that just as dry eye is a chronic condition that took a while to develop, treatment with cyclo-sporine will not make it disappear over-night. Patients need to realize that it may be several weeks and occasionally even longer before they notice any improvement.

"I stress to patients that, while it often works sooner, they will need to give this medication a 6 to 12 week trial to determine if it is working for them," said Dr. Rapuano.

That point also has implications regarding the role of artificial tear supplementation and use of punctal plugs. Patients are instructed to continue using their artificial tears for symptomatic relief when they begin cyclosporine, but are told that any decision about punctal plugs should be delayed.

"I tell patients that my first treatment choice is to try to get the eye to produce its own healthy tears, and that placing punctal plugs may only keep poorer quality tears or tear supplements on the surface longer," he said. "However, patients are informed that plugs can be inserted if the response to cyclosporine is inadequate."

Patients also are alerted about common adverse events. Topical cyclosporine causes 9transient stinging and burning in about 15% to 20% of users. However, those reactions are generally mild to moderate and self-limiting, usually subsiding within 3 to 4 weeks after initiating treatment.

"Patients who know what to expect with regard to local side effects may be more willing to tolerate them and stay on the treatment," Dr. Rapuano said. "However, there are several strategies for making the instillation more comfortable."

One tactic he recommended is to instill artificial tears 5 minutes before the topical cyclosporine. Chilling the cyclosporine by keeping it in the refrigerator can also help minimize stinging and burning, or if the symptoms are more bothersome, patients can try using their medication only at nighttime for a few weeks until the burning subsides.

Finally, administering a mild corticosteroid, such as loteprednol 0.2% to 0.5% (Alrex, Lotemax) 5 minutes prior to instilling the cyclosporine can help mitigate stinging. However, the steroid should be used for only 1 or 4 weeks and then stopped.

Cost issues Patients paying out of pocket also need to be aware that topical cyclosporine is very expensive. To cut the cost of treatment in half, Dr. Rapuano recommended that each vial be used for the morning and nighttime doses in a single day rather than being discarded after one use.