Do I Really Need All These Drops and Why Do They Cost So Much?
January 11, 2006
Norma Devine, Editor
On Wednesday, January 11, 2006, Dr. Elliot Werner, a glaucoma specialist, and the glaucoma chat group discussed “Do I Really Need All These Drops and Why Do They Cost So Much?”
Moderator: Welcome back to chat, Dr. Werner. Our topic tonight is, “Do I Really Need All These Drops and Why Do They Cost So Much?” Would you start, please?
Dr. Elliot Werner: Control of glaucoma is not primarily dependent on pressure level. It is dependent on the behavior of the optic disc and visual field. If the disc and visual field are stable, the glaucoma is controlled. If not, the glaucoma is not controlled and additional treatment is needed.
P: What do you mean by “behavior” of the optic disc?
Dr. Elliot Werner: Whether or not it gets worse over time.
P: Please explain the difference between a stable and an unstable optic disc.
Dr. Elliot Werner: A stable disc is one that is not getting worse over time. An unstable disc is one that is getting worse as time goes by.
P: What changes in the disc show it is getting worse? How can you remember what the disc looks like from visit to visit?
Dr. Elliot Werner: An increase in cupping indicates the disc is getting worse. We make drawings of the disc, take photographs, and do tests like HRT (Heidelberg retinal tomography) or OCT (optical coherence tomography).
P: Then I suppose it is important to be followed by the same doctor. Isn’t looking at cupping and making a drawing rather subjective?
Dr. Elliot Werner: Drawings and examinations are subjective, but photographs, optic disc imaging and automated visual fields are not. They can be easily transferred from office to office.
P: How often should photographs be taken and optic disc imaging performed?
Dr. Elliot Werner: About once a year in most patients.
P: Is the loss of the optic disc the cupping that the doctor sees?
Dr. Elliot Werner: No. It’s the configuration of the actual nerve tissue surrounding the cup, and the nerve fibers on the surface of the retina.
P: How can a doctor tell if a patient has a damaged optic disc? I have a disk diameter of 1.95 mm and cupping is .88. What would you say the percentage is?
Dr. Elliot Werner: Determining if the optic disc is damaged, and by how much, is a difficult and complex task. It’s one of the things we spend years in school and residency and fellowship trying to master. There is no short or easy answer to your question.
P: Why would a doctor in a teaching hospital setting not be ordering those tests every year?
Dr. Elliot Werner: It’s hard to answer that question. Sometimes, for technical reasons, you cannot get an adequate image on some patients. Sometimes the patients insurance doesn’t cover the cost of the test, and the patient is not willing to pay for it. Some doctors honestly believe those tests are of no value, but I don’t agree.
P: Why would a doctor add medication, rather than change to different medication?
Dr. Elliot Werner: There is a tendency on the part of many doctors to add medication, rather than switch medications. The response of an individual to a particular medication is hard to predict. If one medication either doesn’t work or doesn’t work well enough, the logical thing to do is to switch to another to see if you can find a medication that will control the glaucoma. It is my impression that many patients on three or four medications do not need all of them. They are using that many because the doctor ADDED another medication, rather than switch and find out what happens.
P: How many drops are too many drops?
Dr. Elliot Werner: More than are needed to get the desired treatment effect. Using medications is difficult, risky, and expensive. The more medications a patient uses, the greater the risk of side effects, the greater the expense, and the greater likelihood of failure of compliance on the part of the patient. My personal tendency if a patient cannot be controlled on two medications, depending on the type of glaucoma and the nature of their problem, is to consider laser or surgical treatment.
P: It seems that doctors keep adding drops without necessarily stopping others. Is it possible to stop one of the old drops when a new one is added?
Dr. Elliot Werner: Yes, my point exactly. I often try switching, instead of adding, and only add if I cannot find one medication that controls the situation.
P: I was reluctant to stop using one of my eye drops last year when the doctor wanted me to give it a try. How do you help patients overcome the fear associated with stopping a drop, if they feel it is working for them? (I did stop and am okay, so far.)
Dr. Elliot Werner: If I believe that stopping a medication for a short time will do no harm, I tell the patient that and see them within a week or two to reassure them that the pressure is still okay or, if not, to intervene before any additional damage occurs.
P: How and why do the eye drops stop working?
Dr. Elliot Werner: There are several possible explanations. (1) The glaucoma gets progressively worse and becomes harder to control. (2) The patient develops resistance to the medication, a phenomenon called tachyphylaxis. (3) The patient develops side effects, and therefore stops using the medication regularly because it hurts or makes them feel sick.
P: Why is it necessary to use both timolol and Xalatan?
Dr. Elliot Werner: If one medications controls the situation, it is not necessary to use both. Many patients, however, cannot be controlled on one medication. A combination of Xalatan and timolol works very well in many patients.
P: Should more than one kind of glaucoma eye drop be tried before SLT (Selective Laser Trabeculoplasty) is tried?
Dr. Elliot Werner: That depends on the situation. SLT is a safe procedure, with a low risk of side effects. In many cases, it is actually safer than medication and equally effective. So, often we will offer SLT to that patient, instead of adding a second medication or trying too many medications, one after the other.
P: Why do doctors add medications instead of trying something different?
Dr. Elliot Werner: I am not sure. Probably to reduce the number of times the patient has to come back to the office.
P: When I first started taking drops (timolol) the dose was a .5% solution two times a day. Because I felt too many side effects, I kept asking the doctor to reduce the strength, until we had it down to .25% just once a day. That was just one quarter of the original dose.
I didn’t resent it, because I figured the doctor was taking a “safety first” approach when I first saw him, and he was happy to let me try reducing the dosage. But I’ve often wondered, why not start with a lower does and then increase when necessary rather than the other way around?
Dr. Elliot Werner: In general, good medical practice is to use the lowest dose of a medication that will achieve the desired effect. Therefore, the doctor should start with the lowest dose, and increase the strength if necessary. Again, this way of doing things increases the number of visits and requires more time, but is safer in the long run.
P: What is the rationale behind using eye drops in only one eye of newly diagnosed glaucoma patients, and having them return to the office in a week or two before adding the drops to the other eye?
Dr. Elliot Werner: In a one-eyed trial, the untreated eye is used as a control. The eye pressure fluctuates a lot, especially in glaucoma patients. If you start treating both eyes and the pressure goes down in both eyes, you don’t know if that is due to a drug effect or random fluctuation. If you treat one eye and the pressure goes down in one eye and stays up in the other, you know how much effect you are getting from the drug.
P: What about the crossover effect of drops and the one-eye trial?
Dr. Elliot Werner: The only medication that seems to have a significant crossover effect is beta blockers. We recognize that and take it into account in evaluating the response.
P: What is a “crossover effect?”
Dr. Elliot Werner: The crossover effect is the effect of a drug on the pressure in one eye, when the pressure is only being lowered in the other eye. For example, if you use timolol drops in your right eye, the pressure in the left eye will also go down, but not as much.
P: When your optic nerve has already suffered damage, then surely a rise in intraocular pressure must be controlled.
Dr. Elliot Werner: Correct, but you need to know how well your treatment is working. In most glaucoma patients, two or three weeks make no difference in their outcome.
P: If SLT doesn’t work, is it okay to add more medications, rather than move on to other options?
Dr. Elliot Werner: Yes, but in that case, surgery might be a better option.
P: What if laser and surgery fail to reduce the pressure or stop the damage? Is it then back to adding drops?
Dr. Elliot Werner: If lasers and surgery fail, you can try eye drops again, but they didn’t work the first time and probably won’t work the second time. You then have a major clinical problem trying to get those patients under control.
P: Does a laser procedure suggest reduction of drops?
Dr. Elliot Werner: If the laser is successful, reducing the drops can be tried.
P: I am now on Lumigan, Alphagan P and Azopt. My doctor says I have now tried all existing classes of drops, so he will not have a choice if those stop working. Are there new types of glaucoma medications being studied?
Dr. Elliot Werner: The only other class is beta blockers, such as timolol, but that is not new.
P: Are there any new prostaglandin drops on the horizon?
Dr. Elliot Werner: Not that I know of, but drug companies tend to be rather secretive about products in the pipeline.
P: It seems that a good number of glaucoma patients using drops have reactions to the BAK preservative used in some of the medications. Yet preservative-free versions of the drops — which are available for some of the medications — don’t appear to be readily offered before moving on to surgery. Why not?
Dr. Elliot Werner: Preservative-free drops are difficult to obtain and tend to be very expensive. In patients with preservative allergies, they are a reasonable alternative.
P: What affects how a drug is priced?
Dr. Elliot Werner: The cost of the research to develop the drug, the need for the drug company to realize a return on its investment, and the need to keep shareholders happy. Supply, demand, and competition from other drugs probably also have an effect.
P: How do insurance companies determine what they will and will not cover?
Dr. Elliot Werner: It all boils down to money. The insurance companies don’t seem to have any interest in what the patient and the doctor think is best. They want to control their costs and make a profit.
P: Here are prices of the three glaucoma drugs I use:
Lumigan, 0.03%, 5 ml, $133.99, U.S. ($99 Canadian pharmacy).
Alphagan P, 0.15%, 10 ml, $74. 99, U.S. ($45 Canadian pharmacy).
Azopt, 1%, 10 ml, $88.99, U.S.
Fortunately, I pay a lot less than that for the drops on my insurance plan. Care to comment?
Dr. Elliot Werner: That demonstrates the power of the drug companies having to deal with a large purchaser, in this case the Canadian government health plans. We see the same thing in the U.S. in the Veterans Hospitals. Because the VA (Veterans Administration) is such a huge purchaser, they can dictate, to some extent, the price they will pay, and the VA gets drugs at costs far below retail.
P: Yes, but what happens when we no longer have good insurance plans?
Dr. Elliot Werner: You pay out of pocket. If you can’t afford your medication, the prevailing attitude in the USA at the moment is “tough.”
P: If you don’t have drug insurance, don’t be shy about asking for samples the doctors get from the pharmaceutical companies.
P: Are there many companies making generic drugs to help lower costs?
Dr. Elliot Werner: In general, when a drug comes off patent, generic companies will begin to offer it, and that certainly lowers the cost to consumers. The problem is that many of the newer glaucoma drugs are still covered by patents, so they are not available as generics.
P: Are the quality and ingredients the same in the generic drugs?
Dr. Elliot Werner: That is a source of some controversy. Probably some generics are not the same, but most are. In the early days, there were a lot of problems with quality control at generic manufacturers, but they have improved considerably in recent years.
P: A brochure by Pfizer says: “We want everyone who needs our drugs to be able to get them. So do other drug companies. That’s why we offer help to those most in need through these programs.”
Dr. Elliot Werner: Absolutely correct. Most of the companies do have indigent patient plans and patient assistance plans, but you have to qualify by having a low income and no insurance coverage.
Moderator: The 2005 maximum annual incomes required for free or low-cost drug programs are $19,000 for a single person, $26,000 for a married couple, and $36,000 for a family.
P: Dr. Werner, the following statement about normal-tension glaucoma (NTG) appears in the Merck Manual, and I would appreciate your commenting on it.
“Should NTG be strongly suspected, early treatment may not be prudent. Results of the CNTGS [Collaborative Normal-Tension Glaucoma Study] have shown that NTG is slowly- or non-progressive in the majority of cases. Thus, those patients destined to be slowly progressive or non-progressive derive no benefit from treatment, only risks. It is advocated that patients with NTG be observed for a period to establish the rate of progression or stability in each individual patient.”
I am one such patient, observed but not currently medicated, but I think that approach is actually rare. NTG patients seem to be given eyedrops at the time of diagnosis, without a period of observation.
Dr. Elliot Werner: Again a source of controversy. In NTG patients who do not have advanced disease, 50% or more do not progress — at least over a 5 to 10 year period — and those that do progress, usually do so slowly. A period of observation in such patients is, therefore, often warranted, unless the damage is very far advanced, or the pressures are high normal or borderline.
P: How do you define advanced glaucoma?
Dr. Elliot Werner: Advanced disease is usually defined as loss of more than 50% of the visual field and/or 50% of the optic disc.
P: How difficult is it to establish a rate of progression in NTG patients?
Dr. Elliot Werner: It’s not hard by ordering visual field tests and evaluating the optic disc at regular intervals. It just takes a long time, usually several years, before you can determine with any certainty if there is progression.
P: Wow! I was told I had only moderate damage when diagnosed with NTG four years ago, although I had about 6% cupping then. Within four years of using multiple drops and one failed laser (trabeculoplasty), I have already lost 90% of the optic disc and just had my first trabeculectomy last month. I am to have a trabeculectomy on the other eye as soon as possible.
Dr. Elliot Werner: Then you must have a rapidly progressive form of NTG. That does happen sometimes, but it is unusual.
P: I am 49-years old. I am using Lumigan qd (once a day), Cosopt, bid (twice a day), Alphagan P, tid (three times a day), and have recently added pilocarpine, 4%, qid (four times a day), OS (left eye), and Neptazane, 25 mg, bid (twice a day). I do not have any side effects. Can they occur later? What long-term damage to my eyes is being caused by my using all these medications?
Dr. Elliot Werner: You may not be doing any damage to your eyes. I assume your doctor has a reason for treating you with so many medications, but you might ask the doctor why and if some can be stopped.
P: If a second drop brings intraocular pressure down from 15 to 12 mm Hg, is it worthwhile to take the second drop?
Dr. Elliot Werner: It may be, if 15 mm Hg is judged to be too high a pressure for continued stability of the glaucoma.
P: Do glaucoma eye drops lose effectiveness after a while?
Dr. Elliot Werner: Many glaucoma patients do seem to lose some response to drops after a time. They can then try switching to a different medication.
P: How long do the drugs stay in your system? What if you run out of your glaucoma eye drops, and can’t get can’t get to a pharmacy for a refill for a day or two?
Dr. Elliot Werner: That depends on the drug. Beta blockers can hang around for up to two weeks. Other drugs are cleared much faster. Pilocarpine, for example, lasts about 8 to 12 hours.
P: When eye drops are instilled, why do they sting sometimes and not other times?
Dr. Elliot Werner: I am not sure. That might depend on the temperature of the drop, or what part of your eye it hits when you put it in, or if the eye is a bit irritated or dry when you are putting the drop in.
Moderator: Thank you, Dr. Werner. We hope you can return again soon.