Choices vary for first-line glaucoma therapy

Issue: September 2001

Timoptic, then Xalatan

Kathy Yang-Williams, OD, FAAO: If nonselective beta-blocking agents are not contraindicated, I would select Timoptic XE 0.5% (timolol maleate, Merck) every morning as my first-line agent. This unique gel formulation is now available generically, and its once daily dosing schedule helps to promote compliance in my patients.

Timoptic was the first beta-blocking agent that was commercially available for treating glaucoma and is still considered the gold standard. Although some patients do not respond to nonselective beta-blocking agents, Timoptic XE is highly effective for the majority of patients.

When prescribed for appropriate patients, this medication works well and has few clinically significant side effects. I check for bradycardia as well as for restrictive airway disease before prescribing Timoptic XE. I encourage my patients to use techniques such as punctal occlusion or simple eyelid closure to minimize the potential for adverse side effects.

If non-selective beta-blocking agents are contraindicated, my first-line agent is Xalatan (latanoprost, Pharmacia & Upjohn). This prostaglandin analog works well to decrease IOP and is also effective for patients with non-pressure-dependent glaucoma. Patient compliance is improved with once daily dosing. This medication has an excellent safety profile with relatively few systemic side effects. The long-term consequences of ocular side effects are not known, and few patients discontinue treatment when cosmetic side effects such as hypertrichosis or hyperpigmentation develop.

Whether or not new prostaglandin or prostamide medications will supplant Xalatan in my treatment paradigm will remain to be seen. These new agents are efficacious, and patients seem to prefer medications that do not require refrigeration. I would like to evaluate more clinical studies and gain more experience with these medications before reconsidering my treatment model.

Kathy Yang-Williams, OD, FAAO, can be reached at TLC Northwest Eye, 10330 Meridian Ave N, Suite 370, Seattle, WA 98133; (206) 528-6000; fax: (206) 528-0014; e-mail: kwilliams@tlcnweye.com. Dr. Williams has no direct financial interest in the products mentioned in her response, nor is she a paid consultant for any companies mentioned.

Lumigan

Anthony Economou, DO, OD: Lumigan (AGN 192024, Allergan) is the best glaucoma medicine for reaching target IOPs, and it has the fewest side effects of any glaucoma medicine. As a glaucoma specialist, I want to be able to prescribe a drop that takes the least chair time from my day and to which patients respond the best. That drop is Lumigan.

The once-daily dosing and the fact that refrigeration is not needed make patients happy and help with compliance. I actively switch my Xalatan and Timoptic patients to Lumigan and consistently reach lower IOPs. Lumigan is the true monotherapy drop. Two large phase 2 trials demonstrated that mean IOP was consistently 2 to 3 mm Hg lower with Lumigan than timolol b.i.d. In my office, Lumigan has provided significantly better diurnal IOP control than Xalatan or Travatan (travaprost, Alcon) in any race. My patients like the Lumigan bottle and the ease of instillation. I like the availability of an opaque 5-mL bottle that is pliable and easy to squeeze. I have no more complaints from patients on receiving a half-full bottle or wasting drops on their cheeks. In today’s world of attorneys, be wary of beta-blockers and their serious side effects.

Anthony Economou, DO, OD, can be reached at TLC Laser Eye Centers, 1323 E. 71st St., Suite 210, Tulsa, OK 74136; (918) 491-6009; (888) 852-2020; fax: (918) 491-6194; e-mail: anthonyeconomou@tlcvision.com. Dr. Economou has no direct financial interest in the products mentioned in his response, nor is he a paid consultant for any companies mentioned.

Travatan

Joseph Sowka, OD, FAAO: Personally, I believe that when a doctor thoroughly questions a patient and considers every possible aspect such as severity of the glaucoma, medical history, ease of usage and affordability of medications, one can find a nearly ideal drug within any category.

That being said, I find that my favorite first-line medication is Travatan (travaprost, Alcon). Clinically, I have been extremely impressed with Travatan’s ability to decrease IOP, and its dosing schedule (once daily at bedtime) is extremely easy. I have personal experience where pressure reduction has exceeded 50% and cases where Travatan has assisted in achieving single-digit intraocular pressures.

Studies have shown that Travatan has an increased effectiveness in black patients when compared to its competitors, and my experience has shown this to be true. My patients tolerate the medication very well, and its safety profile reduces worry about possible systemic contraindications. Of course, I would not use this drug in cases of inflammatory glaucoma, as there is a potential for it being either ineffective or worsening the condition.

I acknowledge that Travatan, like all prostaglandin-like drugs, is not Food and Drug Administration-approved for first-line therapy. Regardless, I feel that the effectiveness, ease of use and safety profile make this drug a front-runner in glaucoma management.

Joseph Sowka, OD, FAAO, can be reached at Nova Southeastern University, College of Optometry, 3200 South University Dr., Ft. Lauderdale, FL 33328; (954) 262-1472; fax: (954) 262-1818; e-mail: jsowka@nova.edu. Dr. Sowka is a member of the Speaker’s Bureau of Alcon Laboratories, the manufacturer of Travatan.