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Low-risk ocular hypertension patients can safely reduce medications
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By using a specific strategy, some patients with hypertension but a low risk of developing glaucoma may be able to reduce their medications, researchers reported in a study recently published in the British Journal of Ophthalmology.
Chan and colleagues conducted a prospective, longitudinal study with 212 eyes of 126 patients.
Participants with ocular hypertension (OH) who were receiving medication to lower their pressure were examined by a glaucoma specialist at Hong Kong Eye Hospital. They evaluated central corneal thickness, vertical cup-to-disc ratio, intraocular pressure and visual field.
Utilizing protocols developed from risk factors identified in the Ocular Hypertension Treatment Study and the European Glaucoma Prevention study, researchers calculated the risk for each patient. Those with a 15% or less 5-year risk of developing glaucoma were asked to discontinue medication that lowered IOP.
Patients receiving one, two or three medications were asked to discontinue one IOP-lowering medication; patients receiving four or more medications were asked to discontinue two. In the majority of patients, discontinuation was based on price of the medication: starting with prostaglandin analogs, carbonic anhydrase inhibitors, α-2 agonists and then β-blockers.
Results showed that 72.6% of patients had a 5-year risk of 15% or lower. At a 1-month follow-up, 5.2% of patients now had a risk greater than 15%, and 13.7% of patients did not show or refused to continue.
Researchers reported that the 69 patients and 107 eyes left in the study discontinued 141 medications. In these patients, mean IOP remained unchanged, mean visual field pattern standard deviation increased, mean glaucoma conversion risk increased and mean defect decreased at a 1-year follow-up. Further, 13 eyes had a 5-year risk of greater than 15% at the end point. As detailed in the study, the total cost of medications saved was $4,596.
"Although cost-effective analyses based on validated risk models have suggested that treating only higher risk patients with OH would result in the greatest net health benefit, decision to treat in a busy clinic is often based on level of IOP and a variety of subjective patient and physician factors, with little attention paid to the calculated risk of developing glaucoma," the authors said. "We found that a targeted, evidence-based strategy of reducing medications in low-risk patients with OH was generally safe in this setting. More than 40% of patients could reduce one or more medications for a year, and only a single eye (which had a low predicted risk of conversion) developed a repeatable visual field defect." – by Chelsea Frajerman
Disclosure: The authors report no relevant financial disclosures.Perspective
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Derek MacDonald, OD, FAAO
Phase 2 of the Ocular Hypertension Treatment Study (OHTS) suggested that patients with ocular hypertension at low risk of conversion to primary open-angle glaucoma could be safely followed while untreated: OHTS participants in the lowest risk tertile had essentially equivalent 13-year conversion rates whether observed (8%) or treated (7%).
Chan and colleagues have proposed, while acknowledging that their results require confirmation over a longer follow-up, that a similar assessment of risk for patients with ocular hypertension currently being treated may allow a significant number to safely discontinue one or more medications, realizing considerable cost savings. Although not part of their study protocol, it seems intuitive that reducing topical medication burden would also mitigate local and systemic adverse events and potentially increase adherence to any ongoing treatment.
In concert with OHTS, this paper speaks to the value of employing a validated risk calculator both prior to and following initiation of treatment of ocular hypertension. Given the risks, inconvenience and expense of medical therapy, we owe it to our patients to make informed treatment recommendations; this is one more means to that end.
Reference:
Kass MA, et al. Arch Ophthalmol. 2010;128(3):276-287.
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