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Immunomodulators become more common choices for ocular allergy therapy
More immunomodulators are coming onto the scene as options for treating common conditions such as seasonal or perennial allergic conjunctivitis or atopic disease. Primary Care Optometry News asked practitioners about the pros and cons of the most popular steroid and nonsteroid options.
Corticosteroids commonly used
The most commonly prescribed steroid medications for treating allergic responses are corticosteroid ophthalmic drops and triamcinolone. “The drops are indicated for the treatment of steroid-responsive inflammation of the palpebral and bulbar conjunctiva, cornea and anterior segment of the globe,” said Scot Morris, OD, in an interview with Primary Care Optometry News. “They are often used alone or in conjunction with topical mast-cell stabilizers or antihistamines to treat ocular allergies.
“They are effective when used short term to treat conditions such as seasonal acute conjunctivitis (SAC),” he continued, “or they may be used for a short duration to get control of the inflammatory process in more chronic processes such as perennial allergic conjunctivitis (PAC), atopic keratoconjunctivitis (AKC) or vernal keratoconjunctivitis (VKC).”
Jill C. Autry, RPh, OD, told Primary Care Optometry News that while corticosteroid ophthalmic drops are indicated for treating ocular inflammatory states such as episcleritis, iritis and postoperative inflammation, she agreed that they are useful in allergy therapy. “In the treatment of seasonal and perennial allergies as well as atopic ocular disease, corticosteroid drops are generally used short-term to quickly suppress the inflammatory response,” she said.
Long-term or routine use of corticosteroids is generally not recommended due to the potential side effects, which can include increased intraocular pressure and cataract formation, said Dr. Morris. Although considered off-label usage, “Restasis (cyclosporine ophthalmic emulsion, Allergan) may be a better choice for more prolonged disease states,” he said.
Triamcinolone is also often used off-label to treat the itching, redness, dryness, crusting and generalized inflammation around the eyes. “It may be used to treat acute allergic dermatitis if the periorbital area is involved in conditions such as PAC or VKC,” added Dr. Morris.
Dr. Autry concurred. “Although most commonly used for skin conditions, the various triamcinolone preparations have been used off-label to treat both allergic and atopic eyelid disease,” she said.
For this type of treatment, the most commonly used triamcinolone dosage strength is 0.1%. “Most people avoid 0.5% anywhere on the face due to the potential for thinning of the skin, and the 0.025% strength doesn’t usually do the job,” said Dr. Autry.
Off-label use of cyclosporine
Restasis is usually prescribed to increase tear production in patients whose production is presumed to be suppressed due to ocular inflammation associated with chronic dry eye. “It is also used by many off-label to treat more chronic forms of allergies,” said Dr. Morris. “However, because of its mechanism of action, it is not best suited for acute allergy conditions such as SAC.”
Dr. Autry added, “It is being prescribed routinely to suppress perennial and atopic allergic ocular disease, specifically because it can be used year-round without the side effects seen with corticosteroids.”
Off-label Protopic, Elidel
Protopic (tacrolimus, Fajisawa) and Elidel (pimecrolimus, Novartis), which are indicated for atopic dermatitis eczema, are also being used off-label in allergy treatment.
Elidel is a nonsteroidal immunosuppressant cream specifically indicated for treating mild to moderate atopic dermatitis when conventional topical treatments are ineffective. “Elidel is generally used by dermatologists,” Dr. Autry said, “although it has a place in atopic ocular disease due to a better side effect profile than topical steroid products.”
Protopic is another nonsteroidal cream indicated for the short-term and intermittent long-term treatment of more moderate to severe atopic dermatitis when other conventional topical steroid therapy does not facilitate a response. Like Elidel, it is also used by dermatologists and is not indicated specifically for the treatment of ocular allergic or atopic disease.
In an interview with Primary Care Optometry News, Bruce E. Onofrey, OD, RPh, FAAO, FOGS, discussed the merits as well as the perils associated with these medications. “They always come after steroids,” he said. “The real advantage of these drugs is that they don’t cause a steroid response.”
Dr. Onofrey said the Food and Drug Administration recently released a statement that said tacrolimus and pimecrolimus are suggested to produce skin cancer, so they are not recommended for off-label use. Dr. Onofrey also mentioned that many lawyers are advertising on the Internet for clients who have used the drug and have developed skin cancer.
Current evidence suggests that tacrolimus is a bit safer and more potent than pimecrolimus, said Dr. Onofrey. While they are not the first choice when treating keratoconjunctivitis, they do have benefits where steroids and antihistamines would not work.
“I would reserve their use specifically for inflammatory conditions — not so much allergic conditions,” he said. “Some allergic conditions, such as AKC and VKC, have inflammatory components to them, as does scleritis, but I wouldn’t use them as a drug of choice principally because of this recent information about skin cancer and lymphoma.”
Dr. Morris echoed Dr. Onofrey’s strong statements. “Better preparations are probably available for treating SAC and PAC,” he added.
Consider the concept of immune disease, said Dr. Onofrey. “Allergy is a mast cell-based, principally histamine-release process,” he said. “That’s for acute allergic conjunctivitis or seasonal allergies. If you go into AKC, VKC or even giant papillary conjunctivitis, all have T-cell based, late-phase inflammatory responses. This is where this class of drugs works, by blocking cellular response.
“The drugs, particularly tacrolimus, are going to be used as immunomodulators, but the time for regular use has not yet come,” he continued. “I think these drugs show promise in dry eye, AKC, VKC and situations where steroids are contraindicated because of potential side effects or where they haven’t worked.”
For more information:
- Jill C. Autry, RPh, OD, can be reached at the Eye Center of Texas, Bellaire, (713) 797-1010; e-mail: jillautry@eyecenteroftexas.com.
- Scot Morris, OD, can be reached at Eye Consultants of Colorado, Conifer, (303) 250-0376; e-mail: smorris@eyeconsultantsofco.com.
- Bruce E. Onofrey, OD, RPh, FAAO, FOGS, can be reached at Lovelace at Journal Center, Albuquerque, (505) 275-4226; e-mail: Eyedoc3@aol.com.
- All three doctors have no direct financial interest in the products mentioned, nor are they paid consultants for any companies mentioned.