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BLOG: Roclatan — Works like a combo, acts like a prostaglandin
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The initial therapy for standard of care in glaucoma has been topical drops for a very long time. Although we are constantly working on better ways to deliver medications and perform surgery, primary and adjunctive therapies still depend on eye drops. The major obstacle remains the same: patient compliance and the factors that influence it. It is great having more drop options, especially after prostaglandin analogues. Unfortunately, we all know our patients’ ability to effectively get these in their eyes remains the major limiting step. This occurs for many factors. Dosing regimens for topical medications can be complicated, which is further exacerbated if the patient has other systemic diseases requiring oral drugs. Other factors include the side effects beyond those to the eyes that can be quite serious, including systemic, and the inability to effectively apply eye drops.
Patients simply do better when these compounding issues that affect compliance are minimized. However, more than 50% of patients need more than one class of therapy. Every time a patient misses a dose, no matter the reason, there is additional damage to the optic nerve. The cumulative effect can be devastating. Currently, the selection of therapy from adjunctive options is simply a compromise among efficacy, safety and dosing instead of an ideal choice. The ideal situation would include maintaining the patient on just one drop a day like a prostaglandin but getting more IOP reduction. Until recently this has not been possible because current medications have not been combined with prostaglandins in the United States.
For these reasons, it is exciting to hear that Roclatan (netarsudil/latanoprost, Aerie Pharmaceuticals) met its primary efficacy endpoint for Mercury 1. It becomes the only phase 3 study to show superiority over latanoprost at all time periods. Roclatan is a combination of Rhopressa (netarsudil, Aerie Pharmaceuticals) and latanoprost but still dosed just once daily at night.
Patients could potentially benefit from the use of Roclatan in numerous ways:
1. Simple dosing of one drop once at night like current prostaglandins (likely the class of medication the patient was already using) to help with adherence.
2. Different mechanism of action from other options in that it improves aqueous outflow through the diseased trabecular meshwork.
3. No known systemic side effects unlike the other currently available adjunctive therapy.
4. No known issues of tachyphylaxis like other adjunctive therapy.
5. Synergistic effect of ROCK/net inhibitor with prostaglandin (Rocket studies demonstrating greater IOP reduction initially for patients who were on prior prostaglandin vs. those who weren’t before washout).
Again, all with one drop, once daily just as their prior prostaglandin use. This equals more effectiveness but with similar, if not better, compliance rates depending on the need of the patient. As usual, we will likely tend to focus on the biggest problem with anything. In the case of Roclatan, this will be the hyperemia rate, which was noted at 50% in the Mercury 1 study but graded as mild in most cases. This would compare favorably with regards to side effects when remembering other medications can have pulmonary, cardiac and renal issues.
We will need to wait for all the data from the clinical trials for Roclatan. However, this could be a safe and effective way to manage a large amount of early to late glaucoma as either standalone or in conjunction with selective laser trabeculoplasty and/or microincision glaucoma surgery.
Disclosure: Teymoorian reports he is a consultant and does research for Aerie.