NHMRC Glaucoma Guidelines - ANZGIG

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NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 9 – Medication Hyperthyroidism Caution is advised when prescribing beta-blockers to patients with hyperthyroidism because these medications may mask clinical signs (e.g. tachycardia) (AMH 2009). Asthma Exacerbation of asthmatic conditions has been commonly reported with the use of beta-blockers, although rarely with the use of prostaglandin analogues (e.g. latanoprost) and cholinergics (e.g. pilocarpine). Because they may exacerbate bronchospasm, non-selective beta-blockers are contraindicated in patients with reversible airways disease (i.e. asthma) (EGS 2003). Selective beta-blockers (e.g. betaxolol) may be used, but with caution, as the tendency to exacerbate bronchospasm remains, although it is greatly reduced (EGS 2003; Japanese Glaucoma Society [JGS] 2004). The severity of an individual’s asthma should be taken into account, and patients with severe asthma may require treatment with medications other than a beta-blocker. A recent Cochrane review suggests that systemic cardio-selective beta-blockers are safe, but should be used with caution, in patients with asthma (Salpeter, Ormiston, Salpeter et al 2002). Evidence Statement • Evidence indicates that using non-selective beta-blockers is generally contraindicated in patients with asthma, however cardio-selective beta-blockers may be used with caution. Chronic obstructive pulmonary disease Patients with chronic obstructive pulmonary disease usually have a minimal reversible airways component, and so are unlikely to experience adverse events from the introduction of a beta-blocker. However the possibility remains for beta-blockers to exacerbate bronchospasm and therefore these medications should be employed with caution. A recent Cochrane review demonstrated the safety of systemic cardio-selective beta-blockers in patients with chronic obstructive pulmonary disease, stating that chronic obstructive pulmonary disease is not a contraindication to their use (Salpeter, Ormiston, Salpeter 2005). Evidence Statement • Evidence indicates using beta-blockers with caution in patients with chronic obstructive pulmonary disease. Preference may be given to using cardio-selective beta-blockers as they are less likely to induce bronchospasm. Cardiovascular disease Beta-blockers have a number of potentially significant interactions with medications used in the treatment of cardiovascular disease. As beta-blockers produce a hypotensive effect, concurrent use with other hypotensive medications can result in an additive effect and possible excessive reduction in blood pressure. This interaction may be more significant in elderly patients as hypotension can increase the risk of falls. As beta-blockers also cause bradycardia, concurrent use with other medications that reduce heart rate can result in potentially fatal heart block. For this reason, National Health and Medical Research Council 125
NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 9 – Medication beta-blockers should not be used together with verapamil, diltiazem or digoxin (unless under specialist cardiac supervision). If a calcium channel blocker must be used, beta-blockers can be used safely with dihydropyridines (i.e. amlodipine, nifedipine, nimodipine) as they have little to no effect on cardiac conduction. However, the potentially additive hypotensive effect remains. It is important to note that the use of beta-blockers is contraindicated in patients with bradycardia (45–50 beats/minute), sick sinus syndrome, second or third degree atrioventricular block, severe hypotension or uncontrolled heart failure (AMH 2009). Beta-blockers may also impair peripheral circulation and exacerbate symptoms of severe peripheral vascular disease and Raynaud’s syndrome. Alpha 2 -agonists should be used with caution in patients with severe cardiovascular disease as these medications may worsen symptoms (AMH 2009). Other medications used in the management of glaucoma are safe in patients with cardiovascular disease. Evidence Statements • Evidence indicates using alpha 2 -agonists with caution in patients with severe cardiovascular disease. A specialist cardiac opinion may be required for individual cases. • Evidence indicates using beta-blockers with caution in patients with existing heart disease. Using these medications is contraindicated in patients with bradycardia (45–50 beats/minute), sick sinus syndrome, second or third degree atrioventricular block, severe hypotension or uncontrolled heart failure. Hepatic impairment Systemic use of acetazolamide (carbonic anhydrase inhibitor) is contraindicated in patients with hepatic impairment or cirrhosis, due to the risk of hepatic encephalopathy (AMH 2009). The manufacturers of topical carbonic anhydrase inhibitors (dorzolamide and brinzolamide) advise using them with caution in patients with hepatic impairment, as these medications have not been adequately studied in this patient group. Evidence Statement • Evidence indicates that systemic carbonic anhydrase inhibitors are contraindicated in patients with hepatic impairment, while topical carbonic anhydrase inhibitors may be used with caution. Renal impairment Systemic use of acetazolamide, a carbonic anhydrase inhibitor, is contraindicated in patients with severe renal impairment (i.e. when CrCl < 10 mL/minute) as there is an increased risk of profound acidosis. In patients with moderate renal impairment it is recommended that the dose be reduced (i.e. when CrCl between 10-30 mL/min) (AMH 2009). It is also important to note that acetazolamide increases the risk of urolithiasis (kidney stones). There is much less information available about the use of topical carbonic anhydrase inhibitors in patients with renal impairment. The manufacturers of topical carbonic anhydrase inhibitors (dorzolamide and brinzolamide) recommend against using them in patients with severe renal impairment, as they have not been adequately studied in this patient group. Therefore, as systemic absorption does occur, the same precautions should be followed as for the systemic use of acetazolamide. 126 National Health and Medical Research Council
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NHMRC Glaucoma Guidelines - ANZGIG

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