How to identify treatment failure and initiate medication switches

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As optometrists, we frequently deal with the complex diagnosis of glaucoma. Although most patients have some awareness of glaucoma, many confuse it with other conditions and often misunderstand the intricacy and seriousness of the disease.

Once diagnosed with any form of glaucoma (eg, primary open angle, angle closure, or any of the secondary types), patients will have to manage this condition for a lifetime. This is why we must focus on educating patients on the need for regular comprehensive eye examinations and highlighting the importance of maintaining treatment during every checkup. As eye care specialists responsible for the health of the ocular surface, we have to establish the need for treatment and provide the necessary assistance to ensure proper disease management.

A fellow optometrist specializing in dry eye disease once said, “My job is to put [the patient] on the least amount of therapy to keep us all happy.” This applies to all medical therapies when educating the patient. Our expertise is crucial in selecting, modifying, supplementing, reducing, and referring treatments when necessary to prevent this irreversible vision disease from progressing faster. Although we may not be able to stop the degradation or deterioration of vision completely, we are obligated to do everything possible to slow it down. That is what makes managing and treating glaucoma such a dynamic and challenging disease.

The first line of therapy

I would love to believe that we live in a world where optometrists have full autonomy over which treatment the patient will receive in their first-line therapy. However, the stack of prior authorizations (PAs) on my desk reminds me that we live in a world of finite means and resources. (Side note: If you have staff doing your PAs, you should thank them every day.)

The first line of therapy in my practice is a branded prostaglandin analogue. Most of my patients will end up with that, but a growing number will receive a generic and substituted alternative for reasons outside of the initial treatment preference (eg, a generic preserved version instead of a preservative-free formulation). Many insurance providers require a “failure” with the generic product before approving a branded medication. We must also be mindful of the swaps at the pharmacy where the patient may not get the prescribed medication. This underscores the importance of the case history and reminds us to have patients bring their medications to any eye examinations for verification. We may unknowingly eliminate a possible therapy because of omission, not by a true treatment failure.

Consider a change in treatment

Internally, we have a decision to make: to change within the class or to add a drop. Depending on patients’ current treatment, there can be benefits to both. Changing within the class can increase efficacy by a few millimeters of mercury, which can have significant long-term effects. Prescribing adjunctive therapy gives us an additional mechanism of action that can have a more robust response. But remember that research findings have also shown that increasing the number of medications and dosages leads to overwhelmingly lower adherence rates.

It is crucial to start by identifying the why. Why are we going to change the medication or treatment plan for the patient? It comes down to risk, change, adherence, and adverse effects. They are all related, but each category has its considerations and affects the patient and their vision differently.

Questions to consider when evaluating an adjustment to a current medication profile include the following:

• Risk: What are the risk factors? Do any of those risk factors affect the patient’s treatment? Is the patient young? Do they have a strong family history? Do they have a low corneal hysteresis or a higher baseline IOP
• Change: What has changed? Are there changes in the retinal nerve fiber layer (RNFL), ganglion cell complex, visual field (peripheral or central), optic nerve size, and neuro-retinal rim thickness? Has the pressure crept up or fallen slightly out of the target range? Has the pressure gone back to pretreatment levels?
• Adherence: Has the patient been taking the medication(s)? Are they refilling at a regular rate? Have they gone a while between visits and do not need a refill? Do they know what they are taking?
• Adverse effects: Are there noticeable allergies, redness, itching, ocular surface disease, or thinning of the orbital fat that may affect the patient’s life and even how the patient sees themselves? Do these adverse effects affect their daily lives?

If sticking with drops, my best practice is for 2 branded swaps in the prostaglandin category before adding another drop. The generic equivalents are “noninferior,” although head-to-head data show a further decrease with branded medications. The second swap in the class ensures we have the appropriate failure before adding a medication. Considering adherence rates, I prefer to maximize the opportunity for a once-a-day drop before adding more medications. In the states where laser privileges are within the scope of practice, I hope clinicians are using lasers more often as first-line therapy.

When adding a second drop, I start with a combination agent. If the patient is not receiving enough treatment with a prostaglandin, we need to be more aggressive in our treatment. Many good combination therapies have better adverse effect profiles than their stand-alone generics.

A real-life example

A 66-year-old man came to the clinic for a comprehensive examination. He had a history of glaucoma and was prescribed a branded prostaglandin analogue. He had not been to the clinic since his eye exam 1 year ago and stopped taking his medication a few months prior to the visit due to the adverse effects (mainly redness). He reported that his coworkers kept asking him if he was smoking or taking drugs. He would laugh it off but was not thrilled at having to repeat himself.

The patient’s IOP was 34 mm Hg and 28 mm Hg in the right and left eye, respectively. There was a change in the RNFL, and thankfully his visual field was stable. However, he needed something different.

This patient checked almost all the boxes regarding a change in treatment protocol and was a candidate for a medication swap. When he was taking the drops, his IOP was much lower (in the teens). However, the adverse effect profile meant we needed a different route. We discussed selective laser trabeculoplasty, but he was hesitant about laser therapy. As he wanted to stay with drops, we considered a preservative-free option. He was more likely to try that because he had been taking drops and knew how to apply them.

In results from clinical studies, preservative-free latanoprost has shown a similar effect on lowering IOP to preserved medications, and with much higher tolerability. Patients reported less burning and stinging, less irritation, and less redness, and preferred the drops to the preserved medications overall.

The patient returned 1 month later to check the IOP and ensure we were on the right track with appropriate follow-up visits. His IOP was down to the high teens (19 mm Hg in both eyes), which I was thrilled about. The patient also reported improved symptoms compared with what he had experienced with previous drops and seemed optimistic about continuing with the treatment.

Relaying the importance of daily adherence

Ultimately, our primary responsibility is to protect a patient’s lifelong vision. Our perspective must evolve from prioritizing immediate benefits to focusing on the patient’s long-term ocular health. This may require a change in our approach to exploring new treatment paths. Thanks to recent advancements, we are now equipped to make more educated decisions regarding a patient’s treatment plan. This includes minimizing the burden on the ocular surface by reducing the use of multiple therapies and considering preservative-free alternatives. Such strategies also carry several benefits for patients, including improved adherence to treatment regimens.

The treatment and management of glaucoma is not a straight road. It is a journey filled with twists and turns and requires us to be diligent in our care. Investing time to educate patients about their eye health, medications, and adherence is essential. Identifying when to switch therapies is vital to preserving vision, increasing adherence, and creating a better experience for the patient.