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Reserve judgment on DREAM study results
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Dry eye is tough. Period. It’s prevalent – an estimated 16 million American adults already diagnosed (Farrand), and likely countless others suffering. It’s incapacitating, causing discomfort, disrupting vision and negatively impacting quality of life. It’s challenging, sending mixed signals and lacking a definitive diagnostic test. It’s exhausting, demanding an unyielding commitment to identifying therapies, individualizing treatments and, perhaps most importantly, ensuring compliance.
While we’ve a great deal to offer our patients, many therapies simply take time to work. This is why patient encouragement is critical, even when prescribing omega-3s. Most of us are omega-3 believers. We’ve read the literature and have witnessed their benefits. However, just when omega-3s have become mainstream, along comes the unexpected. At last month’s American Society of Cataract and Refractive Surgery meeting, Dr. Penny Asbell summarized 1-year data from the Dry Eye Assessment and Management (DREAM) trial, stating, “This NEI-supported clinical trial shows that oral omega-3 is no better than placebo in relieving signs and symptoms of dry eye disease.” Now what do we tell patients? Do we stop recommending omega-3s? How does this impact patient compliance?
Since the Women’s Health Study first alerted us to the benefit of omega-3s in mitigating dry eye in 2005 (Miljanovic et al.), eye doctors have increasingly embraced this adjunct. As a natural anti-inflammatory, omega-3s have been a “feel-good” story, aiding everything from triglycerides to arthritis. Furthermore, given their nonprescription nature, dietary availability and cost effectiveness, omega-3s resonate well with patients – a key consideration in assuring compliance. Despite their positive public image, robust literature and our collective patient care experiences, is it conceivable DREAM could erase all of this?
The Flaum Eye Institute, where I practice, was a DREAM clinical site, and I can attest to the study’s value. DREAM was robust (500+ patients), well designed, meticulously executed, and prudent in its interpretation and conclusions. Like other great NIH studies (think AREDS), DREAM has provided guidance and stimulated debate.
For me, the primary take-home was not that omega-3 supplementation was ineffective, but, rather, that olive oil (control) was effective. Both omega-3 and olive oil, taken daily, improved patient signs and symptoms, with a notable gain in Ocular Surface Disease Index scores. This is a huge consideration, as nothing assures compliance more than patients feeling better. Olive oil’s gains should not come as a surprise, given its anti-inflammatory benefits and integral role in Mediterranean diets. My second take-home centers around the supplement itself. While 2,000 mg EPA and 1,000 mg DHA may seem adequate, would another formulation have provided greater bioavailability? We’ve learned synthesis and formulation are as important as quantity. A final take-home involved adjunctive therapies, which DREAM did not specifically control. Is it conceivable that as patients benefited from the omega-3s they became less inclined to use adjunctive therapies? While only sub-analysis will tell, I think we’d all agree that less need for adjunctive therapy is a good thing, especially as it enhances compliance.
So, what’s next? Initially, we brace for the inevitable. As DREAM ripples through the lay and medical press, there will be questions. The medical community and patients will look to us for guidance and assurance, and our answers will be pivotal in determining the future of omega-3s in dry eye management. My recommendation? Don’t rush to judgment and, above all, do no harm – especially as it relates to compliance.
- References:
- Farrand KF, et al. Am J Ophthalmol. 2017;doi: 10.1016/j.ajo.2017.06.033.
- Linnehan R. DREAM results do not support omega-3 supplementation for dry eye disease. www.healio.com/ophthalmology/cornea-external-disease/news/online/%7B8493176a-92fe-4095-9bd2-098cc71b5bb0%7D/dream-results-do-not-support-omega-3-supplementation-for-dry-eye-disease. Posted April 13, 2018.
- Miljanovic B, et al. Am J Clin Nutr. 2005;doi:10.1093/ajcn/82.4.887.