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Cost may hinder use of new glaucoma drugs
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First-line therapy for glaucoma in the United States is still the prescription of drop therapy. While some glaucoma specialists argue that selective laser trabeculoplasty or even a MIGS procedure in combination with cataract surgery is a competitive alternative for first-line therapy, those options are rarely employed in that fashion.
Nearly all American ophthalmologists start therapy in the patient with mild to moderate primary open-angle glaucoma with a topical drop. The preference of the majority for the first drop prescribed is generic latanoprost once daily at bedtime. Using the GoodRx website as the source, in my market a month’s supply of this drug can be obtained for $12.90. Considering the safety and efficacy profile of this drop, with the typical patient achieving a 5 mm Hg to 7 mm Hg reduction in daytime IOP, to me this is an extraordinary bargain. More than 50% of patients with mild to moderate primary open-angle glaucoma are adequately controlled with generic latanoprost alone once daily. About 30% require a second drop, and a smaller number of patients are on three or more drops.
We have several good generic alternatives for adjunct therapy as well. Timolol given once daily in the morning is a good partner for bedtime latanoprost and is available in my market for $7.42. Other alternatives, which require twice daily to three times a day dosing include brimonidine at $10.86, dorzolamide at $19.85 and the combination drop containing timolol and dorzolamide, generic Cosopt, at $19.85.
My impression after 45 years of treating patients is that compliance and the patient’s ocular surface are far better if no more than two bottles are required for therapy. Therefore, except in rare situations in which I am managing toward surgery, I never request that a patient use more than two bottles of drops. I find myself usually prescribing timolol or generic Cosopt for second-line therapy, expecting a further 2 mm Hg to 3 mm Hg drop in IOP. Adding a fourth drop, according to some well-done studies and my own personal experience, offers minimal incremental pressure lowering, but some patients do benefit from adding generic brimonidine at $10.86. Because I prefer to never burden the glaucoma patient with more than two bottles, I have found the non-preserved compounded triple agent drops from Imprimis with timolol, brimonidine and dorzolamide used twice daily to be a useful alternative ($59 for 5 mL).
In my opinion, these drops with a low cost, long track record and well-understood safety and efficacy profile present very tough competition for the newly released patent-protected branded alternatives. Vyzulta (latanoprostene bunod, Bausch + Lomb), as I review the data, is now our most powerful single agent in regards to IOP reduction with a 1.5 mm Hg greater pressure reduction than generic latanoprost alone. Years ago, when price was no object in my selection of drugs for patients, I believe this drop would have rapidly moved to the top of my list. Unfortunately, today cost is an ever-larger issue, especially with the typical high-deductible insurance plans, increasing co-pays and spotty availability for most new branded drugs. Vyzulta in my market using GoodRx and the lowest priced pharmacy is $376.70 vs. $12.90 for generic latanoprost and $7.42 for generic timolol. I really like the safety and efficacy profile of Vyzulta and have offered it as an option to many patients, but to date I have no patients using it. Zero.
The same problem, to a lesser extent, affects my use of Rhopressa (netarsudil, Aerie Pharmaceuticals), which in my market starts at $257. The potential for a Rho kinase inhibitor to enhance endothelial migration and perhaps function has prompted me to recommend this drop for select patients with combined glaucoma and corneal endothelial disease with edema, and some have accepted the increased cost. It will be interesting to see what market share Vyzulta and Rhopressa can gain in the modern world of managed care, pharmacy benefit managers, high-deductible plans, higher co-pays and so-called step therapy, in which patients need to fail on cheaper treatments before more expensive ones can be offered.
I fear the brave new world we operate in may present a larger challenge than many expect to the adoption of Vyzulta and Rhopressa. I am willing and actually hoping to be wrong and look forward to revisiting this issue in a year or two. Of course, compliance remains a big issue for many glaucoma patients, and I am very excited to access extended-release medications, whether extraocular or intraocular, and see a bright future for them. Innovation continues to be well supported in ophthalmology, but external forces, especially related to cost when third-party payers are engaged, may dampen the adoption of some.
Disclosure: Lindstrom reports he is a consultant for Bausch + Lomb, Aerie, Imprimis and Novartis.