Eyeworld Supplements

There are many factors that correlate with compliance, including dosing regimen, patient lifestyle routines, use of other medication, and side effects. "We are used to hearing that if a medication doesn't burn or taste bad, it isn't good for you," said Dr. Gayton. "The truth is, patients don't like a drop that burns, and they will tend not to use it." Bromday, he noted, is a comfortable drop to use. "It isn't sticky and it does not burn." The number of drops a patient has to use each day is another factor; studies have shown that drops used just once or twice a day may improve compliance over more fre- quent dosing. 3 Meanwhile, non-compliance in glaucoma patients who tend to need two or more instillations of various drops per day has been noted to go up to 59%. 5 Looking into compliance in post-op cataract surgery patients revealed that all were non-compliant at some point in terms of total dose, time intervals, and premature discontinuation of therapy. 6 Different therapies have different advantages and disadvantages. Studies have shown that use of steroids alone for long-term treatment has a greater risk of IOP rise and is attended by a definite increase in macular thicken- ing or CME. 7,8 On the other hand, steroids reduce the amount of arachidonic acid available for the cox enzymes to convert prostaglandins, and it is reasonable to believe, said Dr. Gayton, that using NSAIDs alone may lose some efficacy by missing the lipoxygenase pathway. "Combined therapy can be very efficacious in safely controlling acute and chronic inflammation," he said. "And because we know that the peak incidence of CME is 4-6 weeks, 9 it makes sense to use therapy for at least that amount of time." It's very important to use your NSAIDs long enough especially in high-risk cases, he said. Dr. Gayton switched to using Bromday (at the time marketed as Xibrom) on the basis of results from rabbit and rat studies that demonstrated that the drug remained at stable concentrations in ocular tissues for more than 24 hours. These studies, he said, showed that the drug could be safely used with once-a-day dosing. 10,11 In Dr. Gayton's practice, he begins instillation of drops including NSAIDs and antibiotics several days before surgery. On the question of using generics or branded drugs, "we strongly prefer systemic disorders predisposing them to corneal melts such as diabetes and rheumatoid arthritis need to be followed more closely. In addition, "Always make sure there is no active infection in patients undergoing topical NSAID therapy," said Dr. Kim. Established safety profiles are a very important consideration, he added; for instance, there have been no reports of corneal melt in clinical trials using Bromday. The once-daily dosing of Bromday, which has been reportedly used for up to 3 or 4 months and longer, is particularly relevant for patients at high risk for corneal melt, but also an important consideration for the routine patient. Complications with NSAIDs are fairly uncommon, but it's important to pay attention to high-risk patients. "Multiple factors are involved in corneal melt and NSAID toxicity," said Dr. Kim. "We need further studies to elucidate the mechanisms that are involved and the specific role of MMPs." References 1. Szerenyi K, Sorken K, Garbus JJ, et al. Decrease in normal human corneal sensitivity with topical diclofenac sodium. Am J Ophthalmol. 1994;118:312-315. 2. Sun R, Gimbel HV. Effects of topical ketorolac and diclofenac on normal corneal sensation. J Refract Surg. 1997 Mar-Apr; 13:158-161. 3. Hersh PS, Rice BA, Baer JC, et al. Topical nonsteroidal agents and corneal wound healing. Arch Ophthalmol. 1990;108:577-583. 4. Assouline M, Renard G, Arne JL, et al. A prospective randomized trial of topical soluble 0.1% indomethacin versus 0.1% diclofenac versus placebo for the control of pain following excimer laser photorefractive keratectomy. Ophthalmic Surg Lasers. 1998;29:365-374. My routine Rx: Insights on compliance and dosing The medical literature strongly indicates that non-compliance ranges up to 50% of various dosing regimens. 1 Significantly, compliance worsens with increasing age. 2 "There are three signs of getting old," said Dr. Gayton. "One is losing your memory, and I can't remember what the other two are. The truth is, you do tend to forget. That's just a fact." According to Dr. Gayton, as shown by previous studies, one thing that can improve compliance is less frequent dosing. 3,4 In a survey of Dr. Gayton's own pa- tients comparing Pred Forte (prednisolone, Allergan) and Durezol (difluprednate, Alcon, Fort Worth, Texas), most of them said they preferred Durezol because of its less frequent dosing. August 2012 3 Bromday," he said. "In fact, we tell our patients that if they have to choose between all of the different medications and can only pick one branded drug, we ask them to make that branded drug the NSAID. The NSAID carries the greatest risk and the greatest benefit." In Dr. Gayton's clinic, they use antibi- otics three times a day 6 days before surgery and Bromday 7 days before surgery; the antibiotics are continued out to 14 days because of research that's shown the peak incidence of endoph- thalmitis is 10-14 days. "We'll use NSAIDs at least 6 weeks if possible," he said. "That's one of the big advantages of a drop that's used one time a day because people are much more likely to comply." Dr. Gayton combines NSAID therapy with a steroid, although in non-diabetic patients, the steroid is discontinued much earlier, stopping anywhere from 2-3 weeks. "Patients who are at high risk will continue the steroid for a significantly longer period of time, maybe going out as long as 6 weeks; [we recognize] that we have to follow those patients more closely because of the increased risk of sequela such as ocular surface issues," he added. To help with regard to compliance, Dr. Gayton suggested keeping in mind what he calls the Cs: "You need to have good corneal penetration, you need excellent cox enzyme binding, you need rapid and total clearance of inflammation, and you need to have a drop that's comfortable and convenient to use." References 1. Koberlein J, Kothe AC, Schaffert C. Determinants of patient compliance in allergic rhinoconjunctivitis. Curr Opin Allergy Clin Immunol. 2011;11(3):192-199. 2. Hoy SM, Keam SJ, Keating GM. Travoprost/Timolol. Drugs Aging. 2006;23(7):587-597. 3. Ikeda H, Sato M, Tsukamoto H, et al. Evaluation and multivariate statistical analysis of factors influencing patient adherence to ophthalmic solutions. Yakugaku Zasshi. 2001;121(11):799-806. 4. Cremer J. Medicine Partnerships. Heart. 2003;89 (suppl II):ii19-ii21. 5. Patel SC, Spaeth GL. Compliance in patients prescribed eyedrops for glaucoma. Ophthalmic Surg. 1995;26(3):233-236. 6. Hermann MM, Ustundag C, Diestelhorst M. Compliance with topical therapy after cataract surgery using a new microprocessor-controlled eye drop monitor. Invest Ophthalmol Vis Sci. 2005;46. E-abstract 3832. 7. Raizman M. Macular edema after cataract surgery. Presented at the Royal Hawaiian Eye Meeting; Jan 24-29, 1999; Waikoloa, Hawaii. 8. Wittpenn JR, Silverstein S, Heier J, et al. Acular LS for Cystoid Macular Edema (ACME) Study Group. A random- ized, masked comparison of topical ketorolac 0.4% plus ISTA supplement_EW August 2012-DL_Layout 1 6/3/14 2:36 PM Page 4

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