NHMRC Glaucoma Guidelines - ANZGIG

More documents

Recommendations

Info

NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 9 – Medication and actions of medications available for glaucoma management are also continually changing, as a result of ongoing research. For instance, current evidence supports the use of medication to lower IOP as having the most beneficial effect on prognosis. However Costa, Harris, Stefansson et al (2003), in a systematic review of studies investigating ocular blood flow improved by medications, indicated that reducing the IOP may not be the only way to treat glaucoma. This review suggested that in the future, glaucoma may also be treated by employing strategies that are additive, or synergistic, to IOP control. Table 9.1: Medications available in Australia that are used in the management of glaucoma Preparations by class Prostaglandin analogues Latanoprost 0.005% Travoprost 0.004% Bimatoprost 0.03% Beta-blockers Non-selective agents Timolol 0.25%, 0.5%, 0.1% Levobunolol 0.25% Selective agents Betaxolol 0.25%, 0.5% Proprietary-fixed combinations Mechanism of action Increase aqueous outflow Decrease aqueous production As for individual components Efficacy Combigan (brimonidine 0.2%/timolol 0.5%) 25-30% 2x Cosopt (dorzolamide 2%/timolol 0.5%) 2x DuoTrav (travoprost 0.004%/timolol 0.5%) 1x Xalacom (latanoprost 0.005%/timolol 0.5%) 1x Alpha2-agonists Brimonidine 0.2% Apraclonidine 0.5% Carbonic anhydrase inhibitors Topical Dorzolamide 2% Brinzolamide 1% Increase aqueous outflow and decrease aqueous production Decrease aqueous production Daily dosage Washout period Order of treatment choices 25-30% 1x 4-6 weeks FIRST 20-25% 1x to 2x 2-5 weeks FIRST As for individual components SECOND 20-25% 2x to 3x 1-3 weeks SECOND 15-20% 2x to 3x 1 week SECOND Systemic Acetazolamide 250mg 25-30% 2x to 4x 3 days THIRD Cholinergics (Miotics) Pilcarpine 1%, 2% Carbachol 1.5%, 3% Increase aqueous outflow 20-25% 3x to 4x 3 days THIRD National Health and Medical Research Council 109
NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 9 – Medication Point of note In the majority of cases, medication is the first choice of management for patients with glaucoma. There is an ever-increasing range of medication options and regimens that can be tailored to individual needs. The selection will depend upon glaucoma subtype, stage of disease and personal situation. Starting medication regimens Health care providers and patients should choose medications based on the greatest chance of achieving target IOP, the best safety profiles, the most convenient delivery method and most affordable (South-East Asia Glaucoma Interest Group [SEAGIG] 2003). To facilitate adherence to medication regimens, health care providers should start with the simplest, most appropriate medication. Particularly for OAG, treatment should be initiated at the lowest effective concentration of medication, preferably administered once daily (Royal College of Ophthalmologists [RCO] 2004). There is general consensus that topical preparations are the first choice management for most glaucoma patients. When patients cannot tolerate prostaglandin analogues or topical beta-blockers, they should be offered one of the other topical medications first, prior to being offered a systemic medication. This is due to their improved efficacy, ease of instillation (once daily dosing), lower incidence of side effects, relatively limited contraindications or precautions to use and lack of significant interactions with other medications. Hierarchies of use are outlined in Table 9.1. Combination eye drops are becoming a more popular medication management choice. Anti-glaucoma eye drops can be combined with each other, as well as offered in conjunction with laser therapy and surgical management. Combination eye drops are preferred to two separate instillations of individual medications for improving patient adherence and reducing inconvenience. Currently all available fixed combination eye drops contain timolol with a prostaglandin analogue, carbonic anhydrase inhibitor or alpha2-agonist. It is essential that the components of combination products are carefully considered before prescribing to ensure all precautions and contraindications to use are taken into account. Also, as medications from the same class should not be used in conjunction with each other, it is important that the choice of a combination product does not duplicate existing medication management (i.e. timolol or betaxolol should not be used along with any of the current fixed dose combinations, all of which already contain timolol). The effect of combined topical medications should be measured in terms of IOP reduction, as for single medication preparations. Currently no specific combination of medications has been identified as preferable, in terms of visual field (VF) preservation or ocular nerve head (optic nerve head) health. Systemic administration of acetazolamide may be indicated when patients cannot tolerate topical medications, are unable to safely and effectively instill the medications topically, or are failing to achieve IOP targets and glaucomatous stability. This form of delivery however, is associated with a significantly increased risk of developing side effects. For instance up to 50% of patients treated with acetazolamide do not tolerate it. Therefore laser therapy or surgery is often considered as an alternative at this stage. 110 National Health and Medical Research Council
Page 1:
NHMRC Guidelines for the Screening,
Page 4 and 5:
NHMRC GUIDELINES FOR THE SCREENING,
Page 6 and 7:
Page 8:
Page 12 and 13:
Page 14:
Page 17 and 18:
Page 19 and 20:
Page 21 and 22:
Page 23 and 24:
Page 25 and 26:
Page 27 and 28:
Page 29 and 30:
Page 31 and 32:
Page 34 and 35:
Page 36 and 37:
Page 38:
Page 41 and 42:
Page 43 and 44:
Page 45 and 46:
Page 47 and 48:
Page 49 and 50:
Page 51 and 52:
Page 53 and 54:
Page 55 and 56:
Page 57 and 58:
Page 59 and 60:
Page 61 and 62:
Page 63 and 64:
Page 65 and 66: NHMRC GUIDELINES FOR THE SCREENING,
Page 144: NHMRC GUIDELINES FOR THE SCREENING,
Page 167 and 168:
Page 169 and 170:
Page 172 and 173:
Page 174:
Page 177 and 178:
Page 179 and 180:
Page 181:
show all

NHMRC Glaucoma Guidelines - ANZGIG

Create successful ePaper yourself

Delete template?

Save as template?