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Counseling our dry eye patients: How to enhance compliance with lifitegrast or cyclosporine
A prepared speech with reassurances and useful tips can help patients stay on their medication.
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All of us use an algorithm that guides our dry eye treatment regimen. Mine is basically a combination of the TFOS DEWS II algorithm and the recommendations of the International Workshop on Meibomian Gland Dysfunction. At some point on our treatment ladder, we consider the addition of a prescription medication, such as cyclosporine or lifitegrast.
Both medications are FDA approved, safe and highly effective. They are a mainstay of treatment; the vast majority of dry eye specialists feel that they could not practice medicine as effectively without them. These two agents have their differences, but they have one thing in common: a low but significant discontinuance rate due to side effects.
Restasis and Xiidra
The studies that led to the FDA approval of both drugs document their safety and efficacy. Restasis (Allergan’s cyclosporine 0.05% solution) was approved by the FDA in 2003 to be used as an adjunct for tear production in patients whose tear production is presumed to be suppressed due to ocular inflammation. The most common adverse reaction in clinical trials was ocular burning (17%). Other reactions reported in 1% to 5% of patients included conjunctival hyperemia, discharge, epiphora, eye pain, foreign body sensation, pruritus, stinging and visual disturbance (most often blurring).
The post-marketing Restasis experience reflects reactions that are voluntarily reported from a population of uncertain size, so it is not always possible to reliably estimate their frequency, nor to even establish a causal relationship to drug exposure. Having said that, reported reactions have included hypersensitivity (including eye swelling, urticaria, rare cases of angioedema, face swelling, tongue swelling, pharyngeal edema and dyspnea) and superficial injury of the eye from the tip of the vial touching the eye during administration.
Xiidra (Shire’s lifitegrast 5% solution) was approved by the FDA in 2016 to be used as a treatment of the signs and symptoms of dry eye disease. It was tested in five clinical studies of dry eye disease with 1,401 patients receiving at least one dose of lifitegrast, 1,287 of which received Xiidra. Across these five studies, the most common adverse reactions (15% to 16%) were instillation site irritation/pain and dysgeusia. Infrequent side effects reported by patients have included discharge from the eye, excessively watery eyes, eye itching, head pain, increased amount of blood in the lining of the eye, pain in the eye, and sinus irritation and congestion.
Introductory speech
The vast majority of our patients’ complaints about Xiidra and Restasis center around burning upon instillation, blurred vision and dysgeusia, some more for one drug than the other. I have a short introductory speech that works with either drug and has helped my patients remain compliant:
“I am giving you a prescription for a twice-a-day medication, a prescription eye drop that will help you make more of your own tears, and healthier tears. It is very safe and effective.
“The vast majority of patients have no issues at all, but a small percentage think that it burns upon instillation. If this happens, nothing is wrong, just put the medication in the refrigerator. When it is cold, it feels much better. If it still stings a little, put a cold artificial tear in first to cushion the eye; then instill the cold medicated drop.
“Another small percentage of patients think that this drop tastes funny (you know that anything you put in your eyes will make its way down into your throat 5 minutes later). If this is the case, nothing is wrong; just brush your teeth, use mouthwash or chew a piece of sugar-free gum.
“Occasionally, a patient will notice blurred vision for a short time after instillation. If this happens to you, nothing is wrong; just put the drop in as soon as you swing your legs out of bed in the morning. By the time you are ready to leave the house for the day, the blurring will almost always have passed.”
Occasionally, I have encountered a patient with such prolonged blurred vision after instillation that he/she can take it only at night, just before bed. Although I have not studied this in a clinical trial, these patients seem to get the same clinical effect — eventually — from both Xiidra and Restasis, although more slowly.
Another great tip: A short tapering course of Lotemax Gel (loteprednol etabonate, Bausch + Lomb) is helpful in initiating therapy with either Xiidra or Restasis. The steroid gives extremely fast (same-day) relief from dry eye symptoms and usually masks the stinging that can accompany the initiation of therapy with either agent. I usually give Lotemax four times a day in both eyes for 2 weeks then twice a day in both eyes for 2 weeks.
The extra 30 to 45 seconds that it takes to give the little speech above has increased my patients’ compliance dramatically and decreased the number of calls to the answering service. Most patients just want to be sure that nothing is wrong, which is why I repeat that phrase three times during my short speech. They are also grateful for tips on minimizing these side effects, as they want to stay on the medication and get better. Knowledge truly is power.
- References:
- Restasis cyclosporine ophthalmic emulsion. https://www.accessdata.fda.gov/drugsatfda_docs/nda/2003/21-023_Restasis.cfm.
- Xiidra (lifitegrast ophthalmic solution). https://www.accessdata.fda.gov/drugsatfda_docs/nda/2016/208073Orig1s000TOC.cfm.
- For more information:
- Marguerite B. McDonald, MD, FACS, can be reached at Ophthalmic Consultants of Long Island, 360 Merrick Road, Lynbrook, NY 11563; email: margueritemcdmd@aol.com.
Disclosures: McDonald reports she is a consultant for Allergan, Shire and Bausch + Lomb. Fumuso reports no relevant financial disclosures.