January-February 2020

GLAUCOMA

Pharmaceutical Focus
Bringing Rocklatan into the glaucoma fold


by Maxine Lipner Senior Contributing Writer


Source: Aerie Pharmaceuticals

 

The new fixed-dose combination agent Rocklatan (netarsudil/latanoprost, Aerie Pharmaceuticals), which gained FDA approval in March 2019, is garnering traction in many glaucoma practices. “I think it’s exciting to have the opportunity to have this medication available, especially as a once-daily formulation,” Amy Zhang, MD, said.
For Dr. Zhang, this fixed-dose combination agent brings with it the potential for increased patient compliance. “By having combinations, it allows for less chance of someone not using the drop,” she said, adding that the dosing is easier since it requires instilling just one drop instead of two.
Another benefit of the fixed-dose combination is that fewer preservatives and other additives are placed on the ocular surface where damage/toxicity can result, according to Linda Huang, MD. “Additionally, you’re increasing the likelihood that patients are getting the drop in,” Dr. Huang said, adding that they’re not putting in one drop and having to wait 5–10 minutes to instill another. You don’t risk someone falling asleep before instilling all of their drops, she said.
Valerie Trubnik, MD, said that Rocklatan increased pressure lowering compared to either single agent in the combination, as seen in the FDA trials. “More than 60% of patients achieved greater than 30% reduction, and more patients achieved lower IOPs than with latanoprost or netarsudil alone,” Dr. Trubnik said. This may allow some to attain pressures under 14 mm Hg, something that may be even more important in patients with normal tension glaucoma, Dr. Trubnik noted.
Jacob Brubaker, MD, described a low-tension glaucoma patient who had a pressure of 16 mm Hg on a prostaglandin and Cosopt (dorzolamide hydrochloride/timolol maleate, Akorn Pharmaceuticals) who needed better pressure control. One month after switching to Rocklatan, the patient came in with a pressure of 10 mm Hg. “The beauty of this combination is that while the patient is on four medications, he is still only using two bottles,” Dr. Brubaker said.

Making the switch

Deciding when to use Rocklatan can vary. Dr. Huang views Rocklatan as a good switch for those who are already on prostaglandin monotherapy. “If they need additional therapy, it’s easy to switch them to Rocklatan so that they have two medications on board,” Dr. Huang said, adding that those with compliance issues, as well as those with low-tension glaucoma, can get a real boost from the addition of the netarsudil component in the combination.
Dr. Zhang usually still prescribes a prostaglandin as the first-line agent, but then is amenable to adding Rocklatan. “Instead of adding a beta blocker, I may be more prone to change them to Rocklatan because it’s still at once-a-day dosing and you have two agents instead of adding another bottle of different medication,” Dr. Zhang said.
In Dr. Trubnik’s view, one of the keys to success with Rocklatan is to start patients early. “When it’s added as a third or fourth drop, it gives the patient tremendous hyperemia,” she said. While the FDA study pegged 90% of hyperemia with Rocklatan as mild, Dr. Trubnik found that when it was added late, it wasn’t mild. “It was quite significant and patients were terminating it because they were so unhappy with the physical appearance,” she said.
Dr. Zhang, who tends to use Rocklatan early, finds that only a small portion of patients stop using this because of the hyperemia. “Sometimes that initial hyperemia is due to the sensitivity to the agents, and the eye gets a little better,” she said.
Dr. Trubnik also tells patients about the possibility of red eye, explaining that it’s not an allergic reaction.
Dr. Brubaker said he tells patients one of the mechanisms of Rocklatan is via its vasodilatory effect on the episcleral venous drainage. “I explain that often the cause of the red eye is that their existing conjunctival vessels are dilating to increase outflow of aqueous out of the eye,” Dr. Brubaker said.
In addition to the red eye, another common side effect is verticillate that occur in about 15% of patients. “They have wispy looking deposits in the corneal epithelium,” Dr. Brubaker said. “I haven’t noticed that it causes any visual complaints. It’s more something that I recognize.” After stopping the medication, this usually goes away in about 6–8 weeks.

Weighing the components

Physicians must sometimes decide whether to prescribe Rocklatan or offer latanoprost and netarsudil separately. “I would generally prefer to use the Rocklatan in every almost every situation, if I can, but because netarsudil has been out longer, we do run into some instances where netarsudil is covered and Rocklatan is not,” Dr. Brubaker said. In instances where someone is allergic to latanoprost, he also avoids Rocklatan.
In addition, Rocklatan must be kept refrigerated once opened, while the individual components when bottled separately don’t have to be, Dr. Brubaker pointed out. If this is an issue for the patient, he prescribes the agents separately.
Overall, Dr. Brubaker sees Rocklatan as a nice addition that most patients have been happy with. “We often have other options if it doesn’t work, but it’s always nice to have the opportunity to improve compliance while also improving IOP,” he concluded.

About the doctors

Jacob Brubaker, MD

Sacramento Eye Consultants
Sacramento, California

Linda Huang, MD
Glaucoma Institute of Northern New Jersey
Rochelle Park, New Jersey

Valerie Trubnik, MD
Ophthalmic Consultants of Long Island
Long Island, New York

Amy Zhang, MD
Clinical assistant professor of ophthalmology
University of Michigan
Ann Arbor, Michigan

Relevant disclosures

Brubaker
: Aerie Pharmaceuticals
Huang: Aerie Pharmaceuticals
Trubnik: None
Zhang: None

Contact

Brubaker: jacobbrubaker@me.com
Huang: lindayh@gmail.com
Trubnik: valerietrubnik@yahoo.com
Zhang: amydzhang@gmail.com

Reimbursement tips

• Verify that Rocklatan is effective for the patient by first offering them a sample, Dr. Brubaker advised.
• Once you’ve proven tolerability and efficacy, have the patient go to the pharmacy to determine the copay. If it is high or if the insurance doesn’t cover it, consider other approaches, such as use of company coupons, to get the cost down for patients, Dr. Brubaker said.
• Prep your office to get prior authorizations and also prep the patient so that they don’t get frustrated if it is not covered, Dr. Trubnik said.
• In cases where netarsudil and latanoprost are covered, document that they are doing well on the combination, Dr. Huang recommended, adding that you can include the reasoning for prescribing Rocklatan, such as compliance or decreasing medication burden.
• Keep in mind that it can take time to figure out reimbursement issues, Dr. Brubaker said. During this period, offer patients another sample to help them get through the paperwork process.

Bringing Rocklatan into the glaucoma fold Bringing Rocklatan into the glaucoma fold
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2020-01-13T13:10:59Z
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