May 2020


Revolution in Glaucoma Medications
Barriers to adherence in glaucoma medical therapy

by Ellen Stodola Editorial Co-Director

“Patients may also have difficulty adhering to glaucoma medications because they don’t appreciate any improvements in their vision or other ocular symptoms when taking medications.”
—Dana Wallace, MD

Physicians face a number of challenges when treating patients with glaucoma, including adherence to the chosen medical therapy. Whether it’s patient compliance, ability to administer medications, or an issue with obtaining the medication, there are many obstacles impacting this. Experts discussed with EyeWorld some of the biggest barriers, how they address these, and how to handle ocular surface disease, a frequent consequence of glaucoma medical therapy.

Barriers to adherence

Barriers to adherence in glaucoma medical therapy differ from patient to patient, said Kelly Muir, MD. Common barriers include cost, side effects, forgetfulness, not understanding the need for chronic therapy, competing priorities, and concurrent health conditions that make it difficult to physically administer the drops or remember to take them.
“Patients may also have difficulty adhering to glaucoma medications because they don’t appreciate any improvements in their vision or other ocular symptoms when taking medications,” said Dana Wallace, MD. “In fact, [the medications] may actually make their eyes feel worse by leading to redness and burning.”
Robert Noecker, MD, said the first barrier is cost. “In this day and age, I think people acquiring the medications and paying for them over time is the biggest barrier,” he said. Patients may have the same medication for years, then the price might increase unexpectedly. When this happens, Dr. Noecker said it can lead to patients cutting back on the recommended dosage.
Another barrier he described was “people being people.” Patients have to follow a routine, Dr. Noecker said. For this reason, he strives for optimal therapy or drop minimization therapy. He also likes to use SLT. Dr. Noecker finds that many mild glaucoma patients are successful using one drop a day. “Once you add on multiple bottles, I think life gets in the way,” he said.
The last barrier to adherence that Dr. Noecker mentioned was ocular surface issues. Glaucoma patients have a higher rate of ocular surface disease than the general population, he said.
According to Alan Robin, MD, adherence is multifactorial, and one of the problems that ophthalmologists may have is they often only think about the eyes and may forget about systemic conditions requiring medications. “I think adherence is a significant issue in all of medicine,” he said. “We forget that most patients are on a multitude of other medications, [so] by the time you add an eye drop, you’re the fifth or sixth medicine that they have to remember to take.”
In addition, the mean age of glaucoma patients is around 65, Dr. Robin said. Even if these patients have a $20–30 deductible, if they’re on five medications, that adds up, especially to those on fixed or limited incomes.
One of the biggest barriers to adherence, Dr. Robin said, is the communication of the physicians themselves, with many not telling patients the names of the medications, dosing schedules, goals, etc. “Our communication skills have to be improved,” he said.
Another major issue is level of patient understanding, including the level at which doctors describe the optic nerve. “Most patients don’t understand what we are saying,” he said, adding that when he’s having a conversation with a patient, he will ask about social history, profession, and schooling to get an idea of the patient’s health literacy. “We often talk at a level far above their ability to understand.”

Who is nonadherent to glaucoma medical therapy?

“We should remember that all patients may struggle with adherence, being careful to not make assumptions about how well a patient is or is not doing with glaucoma medications,” Dr. Muir said. “Doctors can consider leading the conversation with a statement that softens the guilt that a patient who is struggling might experience and following with an open-ended question,” she said. “An example might be, “It is hard to take eye drops every day. How is that going for you?”’ There is evidence that patients with more advanced disease may struggle with the physical task of drop administration due to visual impairment, so it may be particularly important to assess this skill in the office for these patients, Dr. Muir said.  
Dr. Wallace said uninsured patients or those with poor medication coverage have higher rates of nonadherence. “While elderly patients often have high refill rates, age and accompanying physical difficulties can make administration of medication difficult,” she said. “Other groups that have high rates of nonadherence are those with low health literacy and lack of social support.”

Methods to improve adherence

One thing that Dr. Robin thinks would help improve adherence is to simplify regimens. “We’re fortunate now that we have some wonderful medications available and many are combination medicines,” he said. “If one doesn’t work, rather than adding to it, trying a different one or a fixed combination product might be effective.”
Dr. Robin thinks that the number of times a day the patient takes a medication makes a difference as well. Multiple studies have found that patients remember more often first thing in the morning rather than midday or end of the day, he added.
Dr. Muir said taking the time to educate patients about glaucoma and the natural course of the disease if left untreated can help improve adherence. She also stressed the importance of communicating clearly and verifying patient understanding, asking about barriers in a nonjudgmental way and addressing each barrier specifically. When possible, prescribing a regimen that requires the least number of drops per day and suits the patient’s lifestyle and competing commitments can help. Suggesting generic alternatives to brand name medicines, when appropriate, also helps reduce the cost burden to the patient. Ensure that patients can accomplish the physical task of administering drops by asking them to demonstrate for you. She also suggested involving companions in education efforts. 

Medication tolerance and OSD

Unfortunately, any medication that includes a preservative can lead to ocular irritation. “I find the highest rates of irritation in alpha-2 agonists (especially generics), prostaglandin analogues, and rho kinase inhibitors,” Dr. Wallace said.
She finds that preservative-free formulations are often the best tolerated in patients with ocular surface disease. 
Dr. Wallace said she is quick to offer SLT to this group of patients and is also looking forward to incorporating sustained-release bimatoprost (Durysta, Allergan) into her practice. “If patients have ocular surface disease and are planning to have cataract surgery, I recommend MIGS procedures to decrease their medication burden,” Dr. Wallace said. “These patients may also need to consider other glaucoma surgeries, particularly if their medication burden is high and they have more advanced stages of glaucoma.”
Dr. Muir thinks that it’s important to consider not just the individual medication but the quantity of drops that the patient’s eyes are exposed to in a day. “Combination agents are nice in this regard, as they may offer fewer drops per day, but I don’t usually start with a combination agent in a previously untreated patient,” she said. “Each patient is different and may tolerate one medicine better than another, and starting (or stopping) multiple medications at once muddies the picture.”
Dr. Muir checks the medical record to see if a patient can’t tolerate a particular medication and why so that she doesn’t inadvertently reintroduce that medication years down the road. Non-preserved formulations are often better tolerated, especially if a patient requires multiple medications for pressure control. Unfortunately, they are often cost-prohibitive for many patients. Additionally, patients may be hesitant to use artificial tears if they have been prescribed glaucoma drops unless physicians explicitly tell them that they are OK to use both.
“I tell patients on glaucoma drops that they can use artificial tears (preferably preservative-free) as often as they like, just not immediately after their glaucoma drops,” Dr. Muir said.
In some people, it can make a true difference to switch to non-preserved medications, Dr. Robin said. However, he noted that one barrier often may be the cost of these products. “They are usually more expensive and harder to get,” he said.
He also pointed to the recently approved Durysta bimatoprost implant, which he thinks will be helpful for some groups of patients because it requires no eye drop to be delivered.
Dr. Noecker stressed that the fewer medications you’re putting on the eye to keep the preservative amount down, the better. However, he noted that there are other options, including SLT, preservative-free medications, and decreasing the drop count. “We can customize therapy for a given patient,” he said. “These days, we have more treatment options.”

At a glance

• There are many potential barriers to adherence in glaucoma medical therapy. Patient access issues like cost and ability to effectively deliver the medication are common.
• To address some adherence barriers, physicians suggested combination medications, patient education, and drop and refill reminders.
• Using preservative-free medications may help glaucoma patients who also have ocular surface disease.

About the doctors

Kelly Muir, MD

Associate professor
of ophthalmology
Duke University School
of Medicine
Durham, North Carolina

Robert Noecker, MD
Ophthalmic Consultants
of Connecticut
Fairfield, Connecticut

Alan Robin, MD
Associate professor of
ophthalmology and
international health
Johns Hopkins University
Baltimore, Maryland

Dana Wallace, MD
Thomas Eye Group
Sandy Springs, Georgia

Relevant disclosures

: None
Noecker: Novartis, Aerie Pharmaceuticals, Bausch + Lomb, Allergan, Alcon
Robin: None
Wallace: None



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