NHMRC Glaucoma Guidelines - ANZGIG

NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA
Chapter 9 – Medication
Evidence Statements
• Evidence strongly supports using topical medications as the simplest and safest first choice for
glaucoma management.
• Evidence strongly supports limiting the use of systemic medication to situations where patients cannot
tolerate topical medications, are unable to safely and effectively instill topical medications, are failing to
achieve intraocular pressure targets, or when laser therapy or surgery either had poor outcomes,
or are contraindicated.
• Evidence strongly supports using a topical prostaglandin analogue or beta-blocker in the initial
management of glaucoma unless contraindicated.
• Evidence strongly supports carbonic anhydrase inhibitors and alpha2-agonists as second and third
choice medication management, with dosing regimens of two to three times daily.
Facilitating adherence
Optimum medication management of glaucoma requires a high level of adherence to medication
administration. The largely asymptomatic, chronic and incurable nature of glaucoma is also
responsible for significant non-adherence with treatment, as the adverse effects of not following
a treatment plan are not severe (or are without immediate consequences in the short term)
(EGS 2003). Despite the availability of effective medications, non-adherence in patients with glaucoma
has been reported to vary from 24% to 59% (Tsai 2006 citing Rotchford 1998; American Academy of
Ophthalmology [AAO] 2005a; South African Glaucoma Society [SAGS] 2006). Adherence is influenced
by the frequency of topical medication (drop) instillation, side effects, cost and lack of understanding
of the disease process (SAGS 2006).
Patient education and informed participation in treatment decisions improves adherence as well as
the overall effectiveness of medication management (Osterberg & Blaschke 2005). Patient involvement
is recommended as best practice for the management of other chronic diseases (Holman & Lorig
2000; Lorig, Sobel, Stewart et al 1999; Lorig, Holman, Sobel et al 2000). The literature reviewed for
these guidelines consistently endorsed that health care providers should develop patient-by-patient
understanding of the factors that may constrain their adherence with glaucoma management strategies.
Health care providers should then develop strategies to address patient-specific barriers to optimise
patient adherence to management programs. Understanding patients’ social and behavioural responses
to the diagnosis of a chronic eye condition such as glaucoma is essential for health care providers
to assist them to manage their condition in the best possible manner. Management strategies should
aim to optimise quality of life, and reduce complications whilst decreasing deterioration of the
condition. Self-management strategies that engage patients in their own care are successful compared
with health-professional-directed ‘paternalistic’ care (Nys 2008). Potentially simple, patient-centred
approaches are the most effective long-term strategies for effective glaucoma management.
To maximise patient adherence with medication, health care providers are advised to simplify the
medication regimen wherever possible. The lowest dose of the most effective medication should
be used for each patient in order to reach the target IOP and prevent progression of structural
damage and VF defects. A once-daily medication dose appears to increase patient satisfaction and
adherence can be improved through the use of combination eye drops (Tsai 2006 citing Stewart
2004). Many pharmacies have the capacity to provide a medicines profile, listing the prescription,
OTC and complementary medicines being taken by a particular patient. The profiles are used to
support patients in managing their medicines and can also be used as an effective communication
tool when seeing other health professionals.
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