NHMRC Glaucoma Guidelines - ANZGIG

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<strong>NHMRC</strong> GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 9 – Medication Changing medication regimens Change in well-tolerated medication regimens and the use of additional medications are only supported in situations where target IOP has not been reached despite the patient’s adherence to the regimen. If the initial choice of medication management was ineffective in achieving target IOP, and the IOP response to the medication was poor, switching to a different class of medication is justified. A wash-out period is required followed by a repeated one-eye trial. Exceeding the recommended dosage will not lower IOP further, and might increase the likelihood of side effects. In the presence of an adequate but non-target IOP response, an additional medication may be required to achieve the target. If more than two topical medications are required to lower the IOP, then other treatment options should be considered. Significant side effects are frequently encountered with systemic medication (EGS 2003). In this instance laser therapy or surgery are considered as second choice management options. Evidence Statements • Evidence strongly indicates that, where the medication regimen is well tolerated, the main indicator for changing it is failure to reach target intraocular pressures. • Evidence strongly supports substitution rather than addition of medication when treatment is ineffective. • Evidence strongly supports that when two or more topical medications are ineffective, consideration is given to laser therapy or surgery instead of systemic medications. Medication in acute angle closure crisis For acute angle closure, medical management is usually initiated to lower IOP, to reduce pain and to clear corneal oedema in preparation for laser therapy. Medications that suppress aqueous humor formation (beta-adrenergic antagonists, carbonic anhydrase inhibitors) may be ineffective because they will have decreased capacity to reduce aqueous formation if the ciliary body is ischemic (AAO 2005). Pre-operative cholinergics (miotics) may improve the effectiveness of laser iridotomy or iridoplasty. For emergency cases, the use of systemic medications such as oral/parenteral hyperosmotic medications and oral/parenteral carbonic anhydrase inhibitors should be considered in order to rapidly reduce IOP and avoid permanent damage to both the posterior and anterior segments of the eye. Topical timolol and brimonidine/apraclonidine may be considered (Singapore Ministry of Health [SMOH] 2005) along with topical carbonic anhydrase inhibitors. Post-operatively, topical anti-inflammatory medications are usually also indicated. Saw, Gazzard and Friedman (2003) suggest introducing latanoprost additive medication before glaucoma surgery. Latanoprost appears particularly promising if the IOP is less than 25mmHg, and/or when there have been fewer than three previous failed incisional glaucoma operations. Evidence Statement • Evidence strongly supports using adjunct medications including cholinergics (miotics), hyperosmotic medications and carbonic anhydrase inhibitors to rapidly reduce intraocular pressure prior to surgery. National Health and Medical Research Council 121
<strong>NHMRC</strong> GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 9 – Medication Addressing the impact of comorbidities Older age is a risk factor for OAG, as well as for a range of other systemic diseases (such as diabetes). There is a high probability that elderly patients with glaucoma will also be receiving active treatment for other health conditions. These concurrent conditions limit patients’ capacity to self-treat (for instance cognitive impairment, poor hearing and arthritis). Thus health conditions associated with older age may mitigate against adherence to glaucoma treatment, unless patient-specific management strategies are put in place (SEAGIG 2003). There is thus the potential for age-related comorbidities to impact on the outcome of glaucoma interventions via: • patient adherence to, and persistence with glaucoma medication regimens • interaction of medications for other health conditions which are taken concurrently with glaucoma medications • medication-induced glaucoma resulting from medications taken for other health conditions • side effects from glaucoma medications interacting with comorbid conditions and/or their treatment. There is consistent evidence from the chronic disease self-management literature that patients with multiple chronic diseases can be as well managed, and have successful health outcomes, as patients with one chronic disease. In fact, where another comorbid condition is present that requires regular contact with health care providers, patients might actually be better monitored. Therefore regular treatment for comorbid conditions might improve the potential for good health outcomes for patients suspected of having, or diagnosed with, glaucoma. Figure 9.1 provides an overview of medication decision-making in glaucoma management. 122 National Health and Medical Research Council
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