Expert Interview: Prescribing Generics with Harry A. Quigley, MD

Has the release of generic latanoprost changed your prescribing habits? For example, are you now more inclined to choose travoprost or bimatoprost over latanoprost since you are assured your patient will receive the brand name drug?

Dr. Quigley: Since the release of generic latanoprost, many of our patients have had their drug changed by their pharmacy plans. Obviously this is worrisome to them, and some demand that we write in their behalf to keep the brand name. Under the rules of some of these plans, we have to state that the generic has been tried and was unsatisfactory, that is, that the brand name is medically necessary. Since there are no data on the generics now, we cannot do this. On the other hand, many patients are delighted that their copayment has decreased, and many are choosing latanoprost over the brand names, even those they have been on for a long time. The XLT study suggested equal efficacy among the prostaglandins, but fewer side effects from brand-name Xalatan (latanoprost).¹ If the generic versions of Xalatan are now also cheaper than the other two brands, that will be a strong point for moving even more patients to that instead of the others.

Do you have any experience with generic latanoprost, and if so, what is your assessment with regard to IOP control and patient acceptance or side effects?

Dr. Quigley: In the absence of real data from controlled studies, we can’t say anything definitive now. The fact that we haven’t seen any “adverse” effects is not evidence, and given the variability in patient’s IOPs from visit to visit, it will take a large, controlled observation set to tell anything. It is my understanding that the FDA does not require this, and it would be good if organizations that care about glaucoma and its patients would fund such study. Phase 4 data should be mandated or seriously encouraged of the pharmaceutical companies so that we have real information. By the way, there are or will be more than one “generic latanoprost,” so unless we get in the bottle from the patient and find out which manufacturer it is, we can’t trust the statement that “I’m using the generic” as meaning the same thing across patients. Some or a lot of the current generic is actually Xalatan, I am told, under the brand of a company owned or licensed by Pfizer.

Have you found or developed a system in your practice that helps you keep track of the tier assignment of glaucoma medications for the various health plans in which you participate?

Dr. Quigley: No, it’s too complex and too variable.

Assuming no contraindications, which is your preferred adjunctive medication to add to a prostaglandin analog and why?

Dr. Quigley: Beta blocker generics, since in some patients they can be used once per day, have a lower allergy rate than brimonidine, and they sting less than the carbonic anhydrase inhibitors. But there are contraindications that must be considered—dry eyes and COPD/asthma among them—which precludes beta blockers in many patients, along with COPD/asthma.

How many medications do you consider maximal medical therapy prior to recommending surgical intervention?

Dr. Quigley: Anywhere from zero to 4. We follow the practice of offering surgery, laser and drops as initial therapy to every patient (as suggested in the American Academy’s Preferred Practice Pattern). Then, at each escalation from initial drops (if they chose that), they are reminded that more drops, or laser, or surgery can be an option.

Reference

Parrish RK, Palmberg P, Sheu WP, XLT Study Group. A comparison of latanoprost, bimatoprost, and travoprost in patients with elevated intraocular pressure: A 12-week, randomized, masked-evaluator multicenter study. Am J Ophthalmol. 2003;135:688-703.