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Part 1 of 2: For the ocular surface, less is more
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One of the more promising trends in eye care is the move toward lower-concentration drugs and fewer preservatives in topical medications. Where the ocular surface is concerned, less is clearly more. (See my blog on limbal stem cell deficiency as a complication of chronic glaucoma medications.)
For the record, I’m no great fan of pharmaceutical companies tweaking the formulation of a drug and marketing it as an entirely new product. This is known in the industry as a “line extension,” ie, extending the non-generic status of an approved drug by repackaging it under a different name and new formulation. But frequently with new formulations, we do get real clinical improvement. Think about the risk of allergy with Alphagan (brimonidine 0.2%, Allergan) vs. Alphagan P (brimonidine 0.1% and 0.15%, Allergan). Big difference.
Pairing drugs with preservatives that are gentler, lower in concentration or altogether absent is clearly advantageous, particularly in the case of these glaucoma drugs that can be taken “forever.” Lowering the concentration of the active ingredient (when adequate potency permits this change) is also being a real friend to the ocular surface. Bausch + Lomb gets the nod here for its upcoming release of a substantially lower concentration of bromfenac, which in FDA studies showed equivalent efficacy to the current 0.09% formulation (Bromday). Allergan, too, found a better side effect profile for bimatoprost, at one-third the concentration of the original Lumigan. Finally, with TobraDex ST (tobramycin/dexamethasone ophthalmic suspension 0.3%/0.05%), Alcon certainly extended the profitable life of TobraDex but also delivered our patients a more effective antibiotic formulation with half the concentration of steroid — all possible through the staying power of the new additive, xanthan gum.
We as doctors frequently have to make medication choices for our patients between more expensive brand-name drugs and their generic counterparts. Seventy percent of the time in the U.S., patients get a generic, but we should be grateful to the pharmaceutical industry for at least giving us the choice of brand-name medications that offer a kinder, gentler approach to the ocular surface.
In my next post, we’ll talk about microinvasive glaucoma surgery and how I hope it’ll greatly reduce the need for topical treatment of patients with glaucoma.
Disclosure: Hovanesian is a consultant for Bausch+Lomb and Allergan.