Tolerability and Adherence in the Management of Glaucoma and OHT

Managing open-angle glaucoma (OAG) involves a complex decision-making process to determine appropriate treatment choices. The decisions made by eye care practitioners, in collaboration with their patients, are greatly influenced by various factors, such as efficacy, safety, cost, and patient preferences.

Medication tolerance, which can considerably influence patient adherence, is a significant aspect that is often overlooked and can affect the medication’s continued use and, ultimately, its success.

We need to acknowledge the intricate relationship between tolerability and adherence in the management of patients with OAG or ocular hypertension (OHT). I’ll explore this link in this article, discuss key causes of intolerability, and offer tips for critically evaluating the potential effects of new therapies in these patients.

ON TOLERABILITY AND ADHERENCE

In the context of this topic, tolerability pertains to a patient’s ability to endure the adverse reactions or side effects of a particular treatment without experiencing significant discomfort or inconvenience. Tolerability plays a crucial role in influencing a patient’s adherence to prescribed topical ophthalmic therapy. Because OAG and OHT are both chronic diseases, patients require long-term care to slow down their progression and prevent further potential deterioration in eyesight. However, if patients experience deleterious and intolerable side effects from their topical ophthalmic treatment, they are less likely to follow the specified treatment plan.^1,2 Consequently, patients may encounter deterioration in their quality of life, progression of the disease, and, if left unaddressed, permanent visual impairment.

Patients with OAG or OHT do not have many symptoms that trigger a desire for treatment; in fact, it is often the acumen of the clinician that helps make the diagnosis and decision to treat. Adherence to the treatment thus becomes a critical aspect of management. Nonadherence with topical IOP-lowering medication may lead to significant visual consequences, such as insufficient management of IOP, progression of optic nerve damage, and eventual loss of vision.^3-5 It is essential to understand and address topical ophthalmic medication tolerance and adherence in order to attain optimal results for patients.

Consequences of Intolerance

Below is a list of possible factors that may produce a lack of tolerance.

• Ocular adverse effects can occur with several medicines commonly prescribed for patients with OAG or OHT (eg, prostaglandin analogs, beta blockers, carbonic anhydrase inhibitors).
  • Negative consequences include sensations of stinging, burning, redness, and impaired visual clarity.
  • These symptoms might be bothersome and can disrupt a patient’s daily activities, potentially leading to noncompliance.
• Various systemic medicines are available for the treatment of OAG or OHT; however, they carry the risk of causing adverse systemic effects.
  • These adverse effects include fatigue, dizziness, bradycardia, and breathing issues.
  • Patients who experience these negative reactions may be reluctant to continue their treatment, especially if they see the side effects as severe or disruptive.
• Treatment regimens often involve the administration of many medicines at different intervals throughout the day.
  • This can be a difficult component of therapy.
  • Certain patients may feel overwhelmed by the complexity of adhering to these treatment plans, leading to instances of missed medication doses or irregular medication usage.
• Treatment options may not have insurance coverage or may be perceived as costly.
  • Patients with substantial out-of-pocket expenses may be compelled to decrease their drug intake or forgo therapy entirely, resulting in adverse consequences for their ocular well-being.

TREATMENT EFFICACY AND PATIENT ADHERENCE

Eye care practitioners can undertake various measures to assess the efficacy of glaucoma treatments and improve patient adherence. These steps include the following:

Step No. 1: Engage in Collaborative Decision Making

Engage patients and their caregivers in the treatment decision-making process by discussing the potential benefits and risks of different treatment options, including the tolerability profiles of each option. To optimize treatment strategies for individual patients, it is essential to understand the patient’s preferences and fully address any of their concerns.

Step No. 2: Describe Any Side Effects Prior to Treatment

Regularly inquire about any adverse reactions or side effects patients may be experiencing and promptly address them. Patients should be educated about the possible negative consequences of their medication or medications, and expectations should be managed in advance. Additionally, they should be assured that most symptoms are transient and can be easily controlled.

Consider preservative-free regimens to ensure efficacy while avoiding the unnecessary burden of preservatives (preservatives are intended to allow patients to use multi-dose treatment vehicles). The additive nature of the preservative, most notably in patients with OAG or OHT, can overwhelm the ocular surface and affect the patient’s quality of life.

Other treatment regimens that reduce the sequelae medications have on patients include selective laser trabeculoplasty (SLT) and/or glaucoma drug delivery procedures. SLT has been studied extensively, most recently in the LiGHT trial, which showed the benefits of reducing the medication burden for patients and decreasing the number of invasive glaucoma surgeries necessary for those patients.⁶

The recent addition of the bimatoprost intracameral implant 10 mcg (Durysta, Allergan/AbbVie) and the travoprost intracameral implant 75 mcg (iDose TR, Glaukos) has armed eye care providers with options for decreasing the use of preservatives on the ocular surface, taking the bottle out of the patient’s hand and providing a window of time for IOP reduction with guaranteed adherence.

Step No. 3: Streamline Regimens

Streamline treatment protocols by reducing the number of prescribed medications, reducing the preservative load, or by prioritizing the use of preservative-free and fixed-dose combination products. Patients can be supported in following their prescribed treatment plan with explicit guidance and adherence aids, among other strategies.

Step No. 4: Consider Patient-Specific Factors

When choosing appropriate treatment options, it is important to consider the existence of other medical conditions and lifestyle factors.

Using strategies to oversee patient adherence, such as electronic medication reminders, pharmacy refill data, or regular follow-up consultations where patients bring their medications to each visit, helps verify that patients are adhering to their recommended drug regimen. To promote sustained compliance, it is crucial to identify and overcome any barriers that may hinder adherence while providing continuous support and instruction.

DON’T OVERLOOK TOLERABILITY

When prescribing topical ophthalmic IOP-lowering medications, the level of tolerability plays a fundamental role in determining patient adherence and treatment effectiveness. Eye care practitioners can improve patient adherence to prescribed drugs and consequently enhance long-term visual outcomes by prioritizing tolerability and addressing the factors contributing to intolerance.

It is imperative for eye care practitioners to consider tolerability as a vital aspect of treatment and to actively include patients in the decision-making process when it comes to their treatment options. Doing so will enhance the delivery and results of therapy for patients with OAG or OHT.