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 Figure 9.1: Medication in glaucoma management care decisions Set target IOP Simplest safest effective medication Topical application Uniocular trial Review 3–6 weeks Teach technique Demonstrate Observe FIRST CHOICE THERAPy Prostaglandin analogues Beta-blockers ASSESSMENT Achieving target ranges? Achieving adherence? Stable visual fi eld and optic disc and retinal nerve examination Substitute before addition Repeat uniocular trial ASSESSMENT Achieving target ranges? Achieving adherence? Stable visual fi eld and optic disc and retinal nerve fi bre SECOND CHOICE THERAPy Topical carbonic anhydrase inhibitors Alpha 2 -agonists Combination therapy Systemic therapy if not candidates for laser therapy/surgery THIRD CHOICE THERAPy Combination therapy Systemic carbonic anhydraseinhibitors Cholinergics National Health and Medical Research Council 123
<strong>NHMRC</strong> GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 9 – Medication Managing glaucoma successfully within specific comorbid conditions Diabetes Individuals with diabetes have almost twice the risk of OAG compared with individuals without diabetes (RR 1.93, 95%CI 1.38 to 2.69) (Burr, Mowatt, Hernandez et al 2007). However, the association between systemic disorders, diabetes and the vascular factors implicated in glaucoma is not well understood. As beta1-selective beta-blockers have been shown to be safe and effective in patients with type 2 diabetes, the use of the beta1-selective beta-blocker betaxolol may be considered in patients with glaucoma and diabetes. While the risks associated with topical use of beta-blockers in patients with diabetes are unknown, systemic absorption does occur, and thus they should be used with caution. Patients should be made aware of the potential for glaucoma medications to mask signs and symptoms of hypoglycaemia (e.g. tachycardia, tremor). Evidence Statement • Evidence indicates caution when prescribing topical beta-blockers to patients with diabetes. Depression There are a number of potential interactions between glaucoma medications, depressive states and anti-depressant medications (EGS 2003). Tricyclic anti-depressants have been reported to blunt the hypotensive effect of systemic clonidine (selective alpha 2 -agonist). It is not known whether the concurrent use of tricyclic anti-depressants with topical alpha 2 -agonists (brimonidine and apraclonidine) can lead to interference in IOP-lowering effect, although this is unlikely 3 . Depression is a reported side effect associated with the use of topical alpha2-agonists and beta-blockers. Therefore, as the potential exists for aggravating existing depressive symptoms, caution should be exercised when these medications are used in patients with depression. Tricyclic anti-depressants and selective serotonin re-uptake inhibitors can cause acute angle closure glaucoma in susceptible patients (Li, Tripathi & Tripathi 2008). Evidence Statements • Evidence indicates caution when prescribing alpha 2 -agonists or beta-blockers for patients with depression. • Evidence supports the needs for an ophthalmic consultation for patients at risk of increased intraocular pressure, prior to commencing medications for depression, and periodically during treatment for depression. 3 Source: Product Information from brimonidine (Alphagan®) checked with Stockley’s Drug Interactions 124 National Health and Medical Research Council
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NHMRC Glaucoma Guidelines - ANZGIG

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