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GLA03 08 Section II The Great Quake Everyday Topics Rethought Does the Use of Third, Fourth, a

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Next is dr. searle who will talk about how much medication is too much now that we have so many options talking about third fourth and fifth drug use and delaying surgery good morning joe albert colleagues friends there are a series of questions associated with this session we’d appreciate if everyone respond to the questions we will talk about them at the end and

Also if anyone has any questions please submit them albert mentioned the title of my talk my financial disclosures are all in the pharmacology realm so now there are seven what a great boon for us is treating clinicians and for our patients and the dosing of these medications ranges from once a day to four times a day so the question we’re all asking ourselves what

Is maximum tolerated effective and reasonable iop lowering medication regimen we have a great deal of information about medical therapy there are many evidence-based facts we know if you add a second third fourth etc medication you don’t typically anticipate or get as effective a pressure reduction as if you’re using that drug as first-line we know the duration

Of a third fourth etc medication may be less than when used as a solo agent and the efficacy tends to wane over time there are many factors that reduce compliance particularly the complexity of a medication regimen we worry about nocturnal efficacy which is less with some of our medications and our patients may be progressing during the night time in turday and

Intraday fluctuation have been evaluated in many studies these factors may contribute to progression and there actually is at least one literature review that suggests that a combination drug may decrease these fluctuations conjunctival changes from chronic medical therapy are an issue that we all face when we go to operate our patients and we consider should

We stop the medication should we add steroids or should we cross our fingers and high dose of steroids post-op and we know if you give enough medications for long enough the ocular surface won’t look so nice and the patient will start complaining of blurry vision so we know all the caveats related to got to medical therapy how do we practice well in the early

1990s the ages trial was conducted and this is before the introduction of prostaglandins topical ca eyes and alpha adrenergic agonists the mean number of baseline meds in that study was 2.7 mid 1990s those three classes were approved and you can see the subsequent large-scale clinical trials had baseline number of meds of three or greater more recently in peer

Review articles we see mean baseline meds as high as 3.6 and in cm ii publications with case reports we see medications as high as 5 in an individual patient so what’s the evidence for adding a third or fourth medication there aren’t a lot of studies but i’ll go through what we’ve got so we’re pasady liz a row kinase inhibitor administered twice a day available in

Japan when patients were dosed for 12 months there was an additional 15 to 16 percent reduction of pressure and over two thirds of patients and those patients started with a baseline number of meds of 3.6 so a large number ‘not arsenal that most of you are probably familiar with is the rho kinase inhibitor that was approved in the us and 2017 there was one 3-month

Retrospective study that shows additional pressure reductions of about four millimeters of mercury and it didn’t matter the number of medications patients were taking that was the reduction of iop was similar if you’re on less than three meds or three or greater meds fermanagh dean has been shown to be additive over 12 months in about 50% of patients on baseline of

3 meds and there are many studies that show latina post is additive so there certainly is evidence that third or fourth drugs do add we don’t have long-term evidence but no they work what’s been a game-changer in the last two years or so are the fix those combinations because fisk’s dose combinations address all the caveats mentioned in an earlier slide compliance

Cost complexity of regimen iop fluctuation ocular surface disease etc so we have the list here we have several options so the question i’m going to pose to you is should we be counting the number of medications the number of bottles or the number of daily i drop installations so i put together this chart looking at how many drops you need a day how many bottles

Would translate into a number of meds and you can see that you can dose five medications with only four bottles when you think about our days of pilocarpine we were dosing one medication four times a day now not all of our patients are gonna tolerate four doses or four drop installations a day you have to determine what an individual patient can tolerate but we

Can logistically dose five medications with four drops a day using our fixed dose combination can patients do this yes we all can think of patients in our own practice who dose medications three four five times a day reliably and comfortably and if that patient is stable and comfortable we maintain it if there are issues we need to either simplify the regimen or

Move on so i think we all know the red flags as to when it’s time to move on from medical therapy be it one medication or five medications the i’m going to do better doctor that’s a red flag gotta go on mark variability and pressure from visit to visit may be that patient has intrinsic large fluctuation but most probably they’re not always taking their eyedrops

The patient who always runs out of or doesn’t refill their drops move on or the patient who really doesn’t show up and office when they should another red flag so does the use of the third fourth or fifth drugs delay surgery well we have data that additional medications do lower iop so that should translate in some patients to surgical delay how much medication

Is too much there’s no magic number for medications one patient’s treatment sweet spot is another patients treatment burden so the maximum number that is effective certainly varies markedly and the most efficacious and best tolerated combinations are unlikely to be uniform for all patients so make sure your target pressures achieved the disease is stable using all

The technology we’ve seen earlier today that the patient is truly inherent and that then translates into the correct regimen for an individual patient thank you

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GLA03 08 Section II The Great Quake Everyday Topics Rethought Does the Use of Third, Fourth, a By BS Đoàn Lương Hiền