NHMRC Glaucoma Guidelines - ANZGIG

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NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 9 – Medication Medication interaction Each medication family for the management of glaucoma has the potential to interact with any other, as well as with medications taken for other conditions. The additive effect of glaucoma medications is outlined in Table 9.2, derived from the EGS Guidelines (2003) and modified by expert opinion. The significance and severity of these interactions can vary greatly, so it is essential that accurate and timely information on a patient’s use of all prescription and over-the-counter medications is obtained. Medications for glaucoma may also interact with patients’ medical conditions, regardless of whether medications are being taken for other medical conditions or not. Therefore, for patients with other medical conditions, health care providers should be aware of any precautions or contraindications regarding the use of medications for the management of glaucoma. A summary of these interactions is provided in Table 9.3. Table 9.2: Additive effects of medications used in the treatment of glaucoma (modified from EGS 2003) Class of medication Alpha 2 - agonists Betablockers Topical carbonic anhydrase inhibitor Cholinergic Prostaglandin analogues Alpha 2 -agonists +* + + + - Sympathomimetics Beta-blockers +* +* + +* + Topical carbonic + +* + + + anhydrase inhibitor Cholinergic + + + +/- + Prostaglandin analogues + +* + +/- + good additive IOP-lowering effect - additional IOP-lowering effect is relatively poor * available in combined preparation Evidence Statement • Expert/consensus opinion suggests the need to establish the presence of other disease states when initiating, assessing or altering medication regimens for patients with glaucoma. These include, but are not limited to, diabetes, depression, hyperthyroidism, heart disease, asthma, liver and renal impairment. Point of note Communication between health care providers is important to ensure safe and effective medication management. National Health and Medical Research Council 113
NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 9 – Medication Table 9.3: Summary of medications and their respective contraindications, precautions and interactions Class Contraindications Precautions to use Interactions Prostaglandin Analogues Latanoprost Travoprost Bimatoprost Intraocular inflammation (iritis, uveitis)—relatively contraindicated if active; monitor carefully if history of disease. Aphakia, pseudophakia, torn posterior lens or capsule, known risk factors for macular oedema—increased risk of developing macular oedema NSAIDs (eye drops)— reduce efficacy of prostaglandin analogues Beta-blockers Non-selective agents Timolol Levobunolol Selective agents Betaxolol Reversible airways disease, e.g. asthma—use is generally contraindicated, however cardio-selective agents, i.e. betaxolol, may be used with care. Brady arrhythmia Heart block Diabetes Hyperthyroidism Cardiac Failure COPD—betaxolol preferred Depression— may aggravate Elderly—Systemic adverse effects are more common, e.g. hypotension (may cause falls) Children— May cause bradycardia, bronchospasm and hypoglycaemia Systemic betablockers—potential additive effects Catecholaminedepleting medications Medications that reduce BP, cardiac contractility and conduction— potential additive effects Verapamil— only use under specialist supervision Alpha 2 -agonists Brimonidine Apraclonidine Monoamine oxidase inhibitors therapy Children younger than two years—use with caution in children younger than seven years Severe cardiovascular disease—may worsen; use with caution. Depression— may aggravate CNS depressant: Alcohol Barbiturates Opiates Sedatives Anaesthetics Tricyclic antidepressants Hypotensive agents— potential additive effect Carbonic Anhydrase Inhibitors Topical Dorzolamide Brinzolamide Corneal grafts, endothelial dystrophy—may cause corneal oedema and precipitate corneal decompensation. Allergy to sulfonamides— may increase risk of allergy to carbonic anhydrase inhibitors Severe hepatic/renal impairment None reported, but potential exists for similar interactions as for systemic carbonic anhydrase inhibitors 114 National Health and Medical Research Council
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