Compounded drugs an option for severe dry eye
Click Here to Manage Email Alerts
There are many different types of dry eye disease clinics in North America. No matter what type of practice you might have, it is highly likely that practicing your subspecialty became measurably easier in 2023.
Whether you treat dry eye disease (DED) and associated clinical entities such as blepharitis and meibomian gland dysfunction (MGD) on purpose or only when you cannot avoid them, the arrival of Miebo (perfluorohexyloctane ophthalmic solution, Bausch + Lomb) and Xdemvy (lotilaner ophthalmic solution 0.25%, Tarsus Pharmaceuticals) in 2023 instantly made it easier to achieve success with your patients. Treating mild to moderate disease has become much more straightforward: identify the primary type of DED and any main “drivers” (eg, inflammation, Demodex) and pull up the appropriate prescription in your electronic medical record.
Even those who treat primarily moderate and severe DED are now finding that our advanced treatments have become more effective. Recalcitrant DED in which afflicted patients continue to have symptoms that have a meaningful negative effect on their daily lives requires more sophisticated care to move the symptom needle. Practices that offer in-office procedures still need to do so and, if yours is like mine, are providing these services at roughly the same frequency. Thermal/expressive therapy, high-intensity cleansing treatments to remove bacterial biofilm, and anti-inflammatory light-based therapy such as intense pulsed light, intense regulated pulsed light and low-light level therapy are needed for long-term control of moderate to severe DED.
The difference? With all our new pharmacologic options — AzaSite (azithromycin ophthalmic solution, Théa) has been relaunched again! — your in-office treatments work better.
Sadly, there are patients out there who have DED that is so severe that it thwarts what we can probably call “standard” therapy. Here I would like to propose a treatment classification matrix that I believe is appropriate to our new DED world, one that is consistent with my DED “definition as haiku,” DEWMD: basic therapy (diet, dietary supplements, simple home therapy, prescription therapy, tear production via nasal spray), advanced therapy (serum tears, punctal occlusion with plugs of viscoelastic elements, mechanical lid cleansing, thermal/expressive light-based therapy) and tertiary therapy (compounded medications, central nervous system-active medications, nerve stimulation).
Anyone can choose to do almost everything in the basic therapy category. Opting to include advanced therapy typically involves making a significant investment in both equipment and staff training. Indeed, because many of the in-office treatments are not covered by health insurance, moving from basic to advanced offerings also means that you and your staff now need to become familiar with the rules of the noncovered world, and you all need to be comfortable with discussing prices and fees with your patients. In some ways this is the most challenging aspect of offering advanced therapy.
What is different about offering tertiary therapy is that you are willingly taking on the minority of patients for whom even the newest therapy has proven to be insufficiently effective. This is truly rough terrain, and most practices will reasonably decide not to be the primary DED caregivers for these poor souls. If you do decide to extend your care into the tertiary level, you must be comfortable with basic and advanced therapy to a degree that allows you to confidently determine that you and your patient have reached the edge of treatment wilderness.
There are no mapped-out protocols. There is no GPS. Every patient is an n = 1. You are flying together using astral navigation.
When we have run out of basic and advanced therapies, one of the strategies available to us is the use of more exotic medications that are not available through regular sources such as pharmacies. I am speaking, of course, about compounded medications. Fortunately, there live among us brave souls who have worked hard to uncover these options and to teach us how to use them. My heroes here are also two of my closest professional friends, Drs. Mark Milner and Alice Epitropoulos. Mark and Alice have been generous with their time and expertise. What follows is a laundry list of medications to consider when you have entered the realm of tertiary therapy.
Anti-inflammatory options
Even with steroids of all types, immunomodulators (cyclosporine A, lifitegrast), serum tears and AzaSite, we can still struggle with controlling surface and glandular inflammation. I have patients who do well on topical steroids but are insanely sensitive to preservatives. Preservative-free dexamethasone 0.1% is a godsend for them. Autologous serum tears are perhaps the coolest topical nonprescription therapy ever (I wish I knew who should get credit for them), but they require repeated phlebotomy and all its challenges, and not for nothing, they are expensive. Albumin 5% is a terrific alternative ($65 per month in Ohio) that solves both problems.
Remember, we are in the 0.1% range of patients here; sometimes your anti-inflammatory prescription needs are just as uncommon. Hormonal therapy with testosterone drops 0.03% to 0.5% or ointment 10 mg/gm is available. Refractory inflammation in meibomian glands can be treated with dehydroepiandrosterone (DHEA) 0.5% to 1% two to six times per day. Tacrolimus 0.02% is a macrolide calcineurin antagonist with a different mechanism of action than cyclosporine and lifitegrast for those patients who have stubborn inflammation. Patients with filamentary keratitis that has thwarted all your standard-issue treatments may respond to acetylcysteine 5%. Be aware that this stings; you can decrease the concentration if necessary.
In addition to DHEA, there are a couple of medications that can be compounded to treat severe MGD/blepharitis. Metronidazole 0.5% to 0.75% ointment is the better known of these. Dapsone and spironolactone are two more when you are really running out of options. Got an infection that you think is at least a part of the underlying cause of your ocular surface problems but regular topical antibiotics are not doing the trick? Clindamycin 1% and doxycycline 0.025% to 0.1% can be obtained in compounded form.
Lastly, a shout-out to Steven Wilson, MD, and his team right in my backyard at the Cole Eye Institute at Cleveland Clinic for their discovery of the nearly miraculous effect of losartan for certain types of corneal scars. It is extraordinary, and I encourage you to seek out their published work. Losartan 0.08% four times a day for 2 weeks, then twice daily and assess thereafter. Seriously, high fives to Dr. Wilson and colleagues.
So, where do you get this cool stuff? Sadly, that depends on where you practice. Dr. Epitropoulos and I live in Ohio and are able to get our exotics from a pharmacy in Columbus. Dr. Milner practices in South Florida, but he has pals at VLS Pharmacy in Brooklyn, New York, who ship some of the hard-to-get stuff to him. If you decide to offer tertiary therapy, it is worth the effort to seek a reputable compounding pharmacy near your practice.
I am indebted to Alice and Mark for their work as pioneers in the world of compounded medications for highly complex DED, and I am deeply grateful for the time they gave me while I researched this topic.
Their friendship is a treasure.
- For more information:
- Darrell E. White, MD, of SkyVision Centers in Westlake, Ohio, can be reached at dwhite@healio.com.
Collapse
Read more about
Click Here to Manage Email Alerts