NHMRC Glaucoma Guidelines - ANZGIG

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NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 9 – Medication ■ Chapter 9 Medication Recommendation 11 Reduce IOP by using medication Good Practice Points • Due to potential efficacy and once-daily usage, a topical prostaglandin analogue is usually the first choice, unless contraindicated. When more than one agent is required, fixed-dose combinations should be considered to encourage improved compliance. • Topical medications may be the simplest and safest first choice for treatment, except for pregnant and lactating women. • Facilitate adherence and perseverance with a patient-centric self-management approach to a medication plan. Provide ongoing tailored information (such as from Glaucoma Australia) to reinforce a patient’s understanding of glaucoma and realistic goals of treatment. • Initiate, switch or add medications to one eye, using the other eye as a “control”. In these cases, reassess IOP within 2-6 weeks before treating the other eye. If there is no apparent effect check for adherence. • Teach patients the “double DOT” (Don’t Open Technique and Digital Occlusion of Tear ducts) for 2-3 minutes post-instillation to minimise systemic absorption and to promote ocular penetration of eyedrops. • Demonstrate instillation techniques, observe patient or carer instilling drops and repeat education till ability to instill has been proven. Introduction Medication is generally the first management choice 2 by health care providers for most patients with glaucoma. Medication is used to reduce intraocular pressure (IOP) by enhancing aqueous outflow and/or reducing aqueous production. There are five main families of glaucoma medications, each with recognised actions, side effects and contraindications. When prescribing glaucoma medication, many factors should be considered including IOP-lowering potency, additive effects, interaction with concomitant medications and disease states, side effects and ease of administration. Persistence with and adherence to medication regimens is vital in the management of chronic disease. Glaucoma medication must be suited to an individual patient’s capacity to effectively self-administer. Conventional medication management of glaucoma usually begins with topical eye drops. However, in situations where patients are unable to instill eye drops safely or effectively, or where reduction in IOP is less than desired, oral acetazolamide may be used. This form of delivery however, is 2 NB: First choice refers to medications that a treating health care provider prefers to use as the initial intervention. First line refers to a medication that has been approved by an official controlling body for initial intervention (European Guideline Society [EGS] 2003). This guideline refers to first choice as it provides guidance to health care provider National Health and Medical Research Council 107
NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 9 – Medication associated with a greatly increased risk of developing side effects and, up to 50% of patients treated with acetazolamide do not tolerate it. Systemic use of beta-blockers is not as effective in reducing IOP as topical medications and the concurrent use of topical and systemic beta-blockers should be avoided. Point of note This text is only a general guide to medications. It does not claim to contain all the medications, side effects and contraindications related to the treatment of glaucoma, and only the most common and relevant are discussed. Medication discovery and design is constantly evolving, therefore the information in this guideline has been updated since the publication of the associated systematic review. Before a health care provider commences a patient on a course of medication, it is advised that the product information sheet is carefully read and, if required, an expert opinion sought. Medication families Medications used for the long-term management of glaucoma fall into five classes: beta-blockers, prostaglandin analogues, alpha 2 -agonists, carbonic anhydrase inhibitors and cholinergic agonists. Hyperosmotic medications such as mannitol are given to lower IOP in emergency situations, however as they are not used for long-term management, they are not completely described in this chapter. Glaucoma medications reduce IOP by increasing aqueous outflow and/or decreasing aqueous production. Each medication family has a different method of action, and can have significant side effects. The time taken to achieve maximal reduction in IOP is dependent on both the individual and the type of medication used. Initial reduction in IOP typically occurs within minutes to hours after administration, while maximal reduction in IOP can take weeks to months. For example, the known maximum IOP-lowering effect of prostaglandin analogues occurs after three to five weeks (EGS 2003). Therefore, response to newly initiated medications should be assessed after two to four weeks. When medications are ceased, it is important to note that they may have some continued effect on reducing IOP. The approximate time it takes for IOP to return to baseline levels after ceasing medications, also known as the wash-out period, is listed in Table 9.1. Table 9.1 also provides information on medications available in Australia, their mechanism of action, daily dosage requirements, efficacy, order of treatment choices and wash-out periods. Hierarchies of intervention There is general consensus that medications should be the first choice of management for almost all patients with glaucoma. Even when patients present in emergency situations with acute angle closure, medication is used to reduce IOP, to clear corneal oedema and to reduce pain, in preparation for laser therapy or surgery. There is increasing interest in using laser techniques earlier in the glaucoma management hierarchy. Evidence supports the use of laser therapy as first choice intervention in angle closure and for specific patient groups with open angle glaucoma (OAG) who are at-risk of visual loss within their lifetime. Further details are provided in Chapter 10. The most appropriate point-in-time medication should be prescribed for individuals relevant to their specific disease state. As disease states change, and/or as patients become less (or more) able to manage the administration of a particular medication type, other treatment choices can be made. A wide range of anti-glaucoma medications are available. The literature highlights that the type 108 National Health and Medical Research Council
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