Medical Treatment and Adherence

Prostaglandins (PGs) promote aqueous outflow through uveoscleral outflow

            Advantages:     single daily use

                                    High efficacy

                                    Low short-term fluctuation

                                    Low systemic side effect

                                    Increase ocular blood flow

                                    Neuroprotective effect: prevent glutamate-induced retinal       

                                                                       ganglion cells death

Neuroprotective Effect of PGs

-      Reducing excitotoxic stress

-      Direct binding of prostaglandins receptors on retinal ganglion cells could reduce COX-2 mediated induction of nitric oxide synthase which will decrease ischemic stress

-      Stable and definite IOP lowering effect

Clinical Outcome of 0.01% Brimatoprost

            0.03% Brimatoprost and 0.01%Brimatoprost are not different in lowering IOP and better than Latanoprost or Travoprost in lowering IOP at 3 months

            0.01% Brimatoprost can be used as switching therapy or in NTG

ROCK Inhibitors

            Increase of trabecular meshwork outflow by changing morphology and widening outflow pathway and reduction of out flow resistance

            May combine with other IOP lowering drugs

            Use twice a day (RipasudilR), use once a day (AerieR = Rhopressa)

            No long term drift of IOP reduction

            Side effects: hyperemia but disappear in 2 hours

            IOP-lowering effect may be different among glaucoma subtypes

Glaucoma and Medical Adherence

-Medical adherence

1.        Obtaining the medication

2.        Instilling the drop successfully

3.        Using it at the prescribed time

4.        Doing it regularly

-Barrier to adherence

1.        Provider-related factors (communication and trust)

2.        Patient factors (belief, attitude, health problem e.g. Poor vision, forget)

3.        Medication-related factors (number, dose, side effect, cost)

4.        Environmental factors (socioeconomic status, patient support, transportation)

STEPS

1. Identifying non-adherence

2. Measuring non-adherence

            Observation

            Detecting drug metabolites: measure IOP

            Patient interviews

            Self-questionnaires (overestimation)

3. Improving adherence

            3.1. Provider-patient aspect: communication, trust and education

            3.2. Medication regimen: fixed-combinations

3.3. Don’t forget to decide when laser or surgery is appropriated

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