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Prostaglandins offer greater short-term IOP reduction than other classes
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Bimatoprost, latanoprost and travoprost offered the best results at 3 months for primary open-angle glaucoma in a meta-analysis of 114 randomized controlled trials, according to Tianjing Li, MD, PhD, and fellow researchers in Ophthalmology.
Researchers sought to assess the comparative effectiveness of first-line medical treatments in patients with primary open-angle glaucoma (POAG) or ocular hypertension and provide relative ranking of these treatments, with data from 20,275 participants. Researchers included only trials that compared a single active topical medication with no treatment/placebo or another single topical medication.
Trials were also eligible if they were randomized parallel group trials and 60% or more of participants had a diagnosis of POAG or ocular hypertension, according to the study.
The mean reductions in IOP in at 3 months, from the most to least effective drugs based on surface under the cumulative ranking curve (SUCRA) values, were: bimatoprost (5.61 mm Hg), latanoprost (4.85 mm Hg), travoprost (4.83 mm Hg), levobunolol (4.51 mm Hg), tafluprost (4.37 mm Hg), timolol (3.70 mm Hg), brimonidine (3.59 mm Hg), carteolol (3.44 mm Hg), levobetaxolol (2.56 mm Hg), apraclonidine (2.52 mm Hg), dorzolamide (2.49 mm Hg), brinzolamide (2.42 mm Hg), betaxolol (2.24 mm Hg) and unoprostone (1.91 mm Hg).
Based on SUCRA values, the researchers determined, bimatoprost was the most efficacious drug in lowering IOP at 3 months.
The mean differences in IOP at 3 months comparing bimatoprost 0.03% or bimatoprost 0.01% with placebo are 5.77 mm Hg and 4.74 mm Hg, respectively.
Researchers concluded that the prostaglandin class was more effective than drugs in other classes.
The best-ranking drug for lowering IOP at 3 months is no longer being sold, being replaced by a lower concentration of 0.01%, according to researchers. They also noted that in some developing countries, timolol is the only accessible and affordable option among the top-ranked drugs.
“In some cases, the absolute difference in IOP reduction might be small and may not be clinically meaningful; but on the other hand, ranking allows one to put options in context, for example, in conjunction with considerations such as side effects, patient preference and cost,” researchers wrote. – by Abigail Sutton
Disclosure: The researchers reported no relevant financial disclosures.
Perspective
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Derek MacDonald, OD, FAAO
Which is better, number one or number two? Through network meta-analysis, Li and colleagues ranked the relative effectiveness of common first-line IOP-lowering medications.
Not surprisingly, prostaglandin analogs (PGAs) proved most efficacious, followed by beta-blockers, with levobunolol reducing IOP nearly as well as the PGAs. Brimonidine outperformed the carbonic anhydrase inhibitors (CAIs), which were slightly more effective than betaxolol.
The authors wisely note that while IOP reduction is critical, visual field preservation is the ultimate metric of treatment efficacy. To that end, other considerations may further inform our decision-making:
- Betaxolol, while lowering IOP less than timolol, may preserve visual field more effectively (Grieshaber and Flammer).
- Brimonidine may preserve visual function better than timolol in patients with normal-tension glaucoma (Krupin, et al.).
- CAIs may reduce nocturnal IOP as effectively as PGAs while increasing ocular blood flow, whereas brimonidine and timolol may decrease systemic BP and ocular perfusion pressure (OPP), aggravating glaucomatous damage (Quaranta, et al., Siesky).
- Aggressive treatment of hypertension (particularly when medications are taken in the evening) may reduce OPP, exacerbating retinal ganglion cell and visual field loss (Krasinska, Charlson).
While lowering IOP remains the cornerstone of glaucoma management, neuroprotection and perfusion continue to pique investigators’ curiosity. Now, about your cerebrospinal fluid pressure …
References:
Charlson ME, et al. Ophthalmology. 2014;121(10):2004-2012. doi: 10.1016/j.ophtha.2014.04.016.
Grieshaber MC, et al. Prog Retin Eye Res. 2010;29(1):79-93. doi: 10.1016/j.preteyeres.2009.08.002.
Krasinska B, et al. J Clin Hypertension. 2012;14(10):701-710. doi: 10.1111/j.1751-7176.2012.00694.x.
Krupin T, et al. Am J Ophthalmol. 2011;151(4):671-681. doi: 10.1016/j.ajo.2010.09.026.
Quaranta L, et al. Invest Ophthalmol Vis Sci. 2006;47(7):2917-2923.
Siesky B, et al. Acta Ophthalmol. 2010;88(1):142-149. doi: 10.1111/j.1755-3768.2009.01604.x.
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