At a recent, informal get together, I talked to a friend and local corneal specialist about his experience in prescribing glaucoma medication. One of the subjects was cost.

“I only prescribe medicine my patients can get,” he said.

There are three primary reasons patients go blind from Glaucoma: (1) Patients are not diagnosed; (2) the practitioner is not aggressive enough in treating the disease and (3) patient non-compliance to our prescribed treatment(s). In this article, we'll focus on the third reason. Though the factors for non-compliance are many, the obstacles presented by availability/cost, side effects and drug administration can prove insurmountable for many of our patients.

With this in mind, here, I discuss these issues and provide action steps to address them.

THE ISSUES

• Availability/cost. I practice evidence-based medicine. So, theoretically, I should be able to prescribe what I feel is best. We know the reality often turns out to be quite different, as we have to make our way through a maze of formularies, pre-authorizations and patient co-pays. Translation: The threshold to prescribe what we feel is the best drug is often set very high, with the path of least resistance a generic drug, which does have its value.
• Side effects. Glaucoma drugs, as is the case with an array of medications for a variety of conditions, are not without their side effects. To review: For alpha-adrenergic agonists, they are allergy, burning/stinging, dry mouth, drowsiness, fatigue, headache, high blood pressure and irregular heart rate. For beta blockers, the primary side effects are depression, fatigue, low blood pressure, low libido, slowed heart rate and slow breathing. The carbonic anhydrase inhibitors primary side effects are bitter taste, blurred vision and burning/stinging. Prostaglandin analogue (PGA) side effects can be blurred vision, eyelid/eye color changes, itching, redness and stinging. Additionally, preservative-containing glaucoma drugs are shown to have toxic effects on the ocular surface, inciting or worsening existing dry eye disease (DED). Rho-kinase inhibitor side effects are conjunctival hemorrhages, conjunctival hyperemia, corneal verticillata and instillation site pain. We know all too well that any and all these side effects can hinder patient compliance to what we prescribe.
• Drug administration. The presence of physical (e.g. poor dexterity, etc.) and/or mental disabilities (e.g. Alzheimer’s disease, etc.) in our glaucoma patients can inhibit their ability to comply with the glaucoma drug(s) we prescribe.

ACTION STEPS

Before I provide action steps to address the issues above, I think it’s important to remember that our objective is to maintain and preserve usable vision over these patients’ lifetime. This is based on life expectancy and rate of disease progression. If the condition is relatively stable, typically a PGA is adequate. If the disease progression rate indicates forthcoming vision loss, affecting activities of daily living within normal life expectancy, more aggressive treatment is required.

In my practice, this objective begins with setting a target IOP. I determine this based on the highest IOP (Tmax), patient’s age and VF (especially the mean deviation and VF index) and optic nerve condition. The target is re-evaluated at every visit. If the patient’s disease is progressing despite consistently reaching target IOP, the goal is inadequate and is revised.

If the revised goal is not met, I typically add a combination agent to increase the likelihood of patient compliance. Now, for the action steps:

• Availability/cost. We should consider referring patients to the drug company’s patient assistance programs and generic alternatives provided by compounding pharmacies. (For additional information on patient assistance programs, see https://bit.ly/2YEQ9np .) Compounding pharmacies offer up to four drugs in one bottle. The drug is made at a pharmacy and shipped directly to the patient, potentially bypassing patients’ insurance companies entirely.
• Side effects. We should choose a drug that has the most favorable profile for a given patient. For example, if a patient has existing DED, prescribing a preservative-free drug would make sense.
• Drug administration. We should have our front desk staff tell glaucoma patients, in general, that family members are welcomed at the appointment: the purpose being these family members can be an extra set of ears regarding prescribing information and, potentially, aid the patient in drug administration. Also, we should have our techs show patients how, specifically, to instill their drugs and have patients practice instillation prior to departing our practices.

Further, we should consider selective laser trabeculoplasty, or SLT, which the LiGHT study shows is a more effective first-line treatment than glaucoma drops for the treatment of open-angle glaucoma and ocular hypertensive patients.

TAKE HOME MESSAGE

My cornea colleague mentioned above also stated, “I’d rather prescribe a drug the patient can actually get and will use vs. one I want them to have, but they can’t get or won’t use.” We must remember that patients cannot be expected to comply with the drugs we prescribe, if they cannot access, tolerate or properly instill them. The outlined action steps, along with coupons and the potential of SLT and/or promising MIGS procedures will enable us to best help our glaucoma patients. OM

DR. O'DONNELL is in private practice in Harrisburg, Pa., where he specializes in the diagnosis and management of glaucoma. He is an AAO Diplomate in Glaucoma, a member of the Optometric Glaucoma Society and is board certified by the ABO. He has no disclosures.