NHMRC Glaucoma Guidelines - ANZGIG

More documents

Recommendations

Info

NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 9 – Medication Category B3: Drugs which have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects in the human foetus having been observed. Studies in animals have shown evidence of an increased occurrence of foetal damage the significance of which is considered uncertain in humans. Category D: Drugs which have caused, are expected to have caused or may be expected to cause, an increased risk of human foetal malformations or irreversible damage. These drugs may also have adverse pharmacological effects. Category X: Drugs which have such a high risk of causing permanent damage to the foetus that they should not be used in pregnancy or when there is a possibility of pregnancy. Note: For drugs in the B1, B2, and B3 categories, human data are lacking or inadequate, and sub-categorisation is therefore based on available animal data. The allocation of a B category does not imply greater safety than the C category. Drugs in category D are not absolutely contraindicated in pregnancy (e.g. anticonvulsants). Moreover, in some cases the ‘D’ category has been assigned on a basis of ‘suspicion’ (http://www.tga.gov.au/docs/html/mip/medicine.htm#cata). Glaucoma medications and pregnancy category Category C, B1 and B2 medications would be the preferred medications during pregnancy. Category B3 medications would only be used after consideration of the risks and benefits of treatment. There are case reports of the safe and effective use of all of these medications during pregnancy and no indication for teratogenic effects. However, the current evidence base is not strong, and therefore caution is advised. If topical medications are used, systemic absorption should be minimised with the use of punctal occlusion. Health care providers should contact a specialist pregnancy drug information centre to discuss the risks of glaucoma medication (AMH 2009). Examples of medications in each of the Australian categorisation of risk of drug use during pregnancy are: • Category C: timolol, betaxolol, levobunolol • Category B1: brimonidine • Category B2: pilocarpine • Category B3: apraclonidine, latanoprost, bimatoprost, travoprost, brinzolamide, dorzolamide and acetazolamide. The current evidence base underpinning the medication management of glaucoma during pregnancy is detailed in Table 9.8. Note: The medications in Table 9.8 have been sorted in approximate order of use in pregnancy, i.e. beta-blockers first and the prostaglandins as last choice. Most evidence based review articles, regard beta-blockers and alpha2-agonists as equal choice as first choice medication management, leaving it up to the health care provider to make the risk:benefit assessment. National Health and Medical Research Council 133
NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA Chapter 9 – Medication Table 9.8: Summary of medication management for glaucoma during pregnancy Medication class Beta-blockers Timolol Betaxolol Levobunolol All ADEC Category C Alpha 2 -agonists Brimonidine – ADEC Category B1 Apraclonidine – ADEC Category B3 Cholinergics Pilocarpine – ADEC Category B1 Carbonic anhydrase inhibitors Dorzolamide Brinzolamide Acetazolamide All ADEC Category B3 Prostaglandin analogues Latanoprost Bimatoprost Travoprost All ADEC Category B3 Information on use during pregnancy Suitable if necessary, may cause foetal bradycardia (AMH 2009) The systemic use near delivery of some beta-blockers has resulted in persistent beta-blockade in the newborn. Thus, newborns exposed in utero to timolol should be closely observed during the first 24-48 hours after birth for bradycardia and other symptoms. Use of systemic beta-blockers during the 2 nd and 3 rd trimester has been associated with intrauterine growth restriction, however, there is limited data for topical beta-blockers used for glaucoma (Briggs & Freeman 2005). Apraclonidine, avoid use (AMH 2009). Brimonidine, suitable if necessary (AMH 2009). Limited data available (AMH 2009). No adverse reports from human pregnancies. Probably suitable to use if necessary (Briggs & Freeman 2005). Avoid use; no human data available (AMH 2009). Where the use of carbonic anhydrase inhibitors is deemed absolutely necessary, preference should be made for the use of topical therapies as there are case reports of adverse effects in infants born to mothers treated with acetazolamide during pregnancy (Maris, Mandal & Netland 2005). Avoid use; no data available (AMH 2009). Since prostaglandins increase uterine tone and can cause reduced perfusion to the foetus, general caution is advised. However, if there are compelling treatment indications in a case of severe glaucoma, they should not be withheld. The dosage should be kept as low as therapeutically possible and punctal occlusion used to limit systemic absorption (Schaefer, Peters & Miller 2007). Breastfeeding mothers In the majority of cases, medications used for glaucoma can be used safely in women who are breastfeeding. Particular caution should be exercised however, if a breastfeeding mother is taking beta-blockers or alpha2-agonists. The infant should be monitored closely for evidence of systemic toxicity, although this is unlikely. Both timolol and acetazolamide are listed by the American Academy of Pediatrics (2001) as compatible with breastfeeding. When managing glaucoma in women wishing to breastfeed, consider using the minimum number of medications or concentration sufficient to achieve target IOP. The use of punctal occlusion should also be emphasised to reduce the potential for systemic absorption and therefore reduce potential transfer into breast milk (American Academy of Pediatrics 2001) (Table 9.9). 134 National Health and Medical Research Council
Page 1:
NHMRC Guidelines for the Screening,
Page 4 and 5:
NHMRC GUIDELINES FOR THE SCREENING,
Page 6 and 7:
Page 8:
Page 12 and 13:
Page 14:
Page 17 and 18:
Page 19 and 20:
Page 21 and 22:
Page 23 and 24:
Page 25 and 26:
Page 27 and 28:
Page 29 and 30:
Page 31 and 32:
Page 34 and 35:
Page 36 and 37:
Page 38:
Page 41 and 42:
Page 43 and 44:
Page 45 and 46:
Page 47 and 48:
Page 49 and 50:
Page 51 and 52:
Page 53 and 54:
Page 55 and 56:
Page 57 and 58:
Page 59 and 60:
Page 61 and 62:
Page 63 and 64:
Page 65 and 66:
Page 67 and 68:
Page 69 and 70:
Page 71 and 72:
Page 73 and 74:
Page 75 and 76:
Page 77 and 78:
Page 79 and 80:
Page 81 and 82:
Page 83 and 84:
Page 85 and 86:
Page 87 and 88:
Page 89 and 90: NHMRC GUIDELINES FOR THE SCREENING,
Page 144: NHMRC GUIDELINES FOR THE SCREENING,
show all

NHMRC Glaucoma Guidelines - ANZGIG

Create successful ePaper yourself

Delete template?

Save as template?