Prescribing for Glaucoma in A Tough Economy

When patients are struggling to pay for their medicines, doctors need to pay attention. Here's how this glaucoma specialist works with his patients to help them adhere to therapy.

By E. Randy Craven, M.D.

Most of us are finding out just how insidious the economic downturn has been for our glaucoma patients, upsetting what is often a delicate balance for older patients on a fixed income, and even affecting younger patients who have lost jobs and, consequently, insurance coverage. In fact, in the past, when addressing adherence and persistency issues with younger employed patients, I found finances rarely were part of the equation. They were more likely to be concerned with cosmesis or the convenience of therapy. Now, suddenly, the cost of glaucoma drops is a huge issue for them, and procedures that would obviate the need for drops are out of the question because they don't have insurance.

Some older patients may be facing an increased financial burden exacerbated by the so-called “doughnut hole,” the gap between the initial coverage limit and the catastrophic coverage threshold in the Medicare Part D prescription plan. For these patients, the difference between the cost of a tier 1 medicine (a generic drug at about $7) and a tier 3 medicine (a nonpreferred branded drug at $40 or more) can mean the difference between using a medicine or not.

Based on what I'm hearing from my patients, especially over the last year, money is the number one reason they're having trouble adhering to their glaucoma therapy.

Here's how we can help.

Uncovering the problem

Most of my patients are fairly open about their financial situations. When I ask how they're doing, they may tell me, “My pension has been cut because the market is down, and I don't have as much money as I used to.” That's their way of asking for help with the cost of their medicines. Other patients may beg for samples. Although not as straightforward, the message is the same: “I need help.” Another clue is when patients ask for laser therapy or generic drugs.

Lately, some of my patients who are using prostaglandin analogues have been asking me if they can use a beta-blocker to save money. In fact, I've learned these inquiries often are prompted by the patient's pharmacist. In an average week, at least 2 or 3 educated patients tell me what choices they think they have. They've researched their options and are trying to find out what's less expensive.

Patients also may take it upon themselves to try to stretch their medicines to save money, sometimes to the point of using their drops only on the days when they see me. Obviously, this is a dangerous practice and one we're not likely to uncover easily. It's up to us to look for clues that patients are having problems following the regimen we've prescribed and then find out why.

When patients indicate they're having financial difficulties, I usually ask them how many medications they're using. Sometimes the answer is astounding. I've had people tell me they're using 8 different medicines and they live on $800 a month from Social Security. When you hear a story like that, you realize $100 a month for a glaucoma drop means a lot to them financially. This is not a compliance issue. These patients want to do what's right, especially if you've educated them about the disease. It's a financial reality. They can't afford their medicine. At that point, I know we need to look at changing their therapy.

Economical alternative

The prostaglandin analogues have proven efficacy, safety and tolerability for treating glaucoma.¹ They've been proven to effectively reduce IOP, specifically minimizing IOP fluctuations for the long term.² For these reasons, the prostaglandins are the preferred first-line antiglaucoma therapy among physicians in the United States and Europe.³ However, these drugs are more expensive than other available pressure-lowering drugs.^4,5

Having treated glaucoma patients before the prostaglandin era, I believe the beta-blockers still have a place in our armamentarium. Timolol hemi-hydrate (Betimol; Vistakon Pharmaceuticals, LLC), for example, is an excellent adjunct to the prostaglandins to lower pressures that are still too high. It is indicated for twice-a-day dosing and for once-daily dosing after IOP has been maintained. In addition, a subset of specialists like to use it as primary therapy to reduce elevated IOP, particularly for pseudophakic patients and for patients who have had prior filtration surgery. It's also a good option for patients looking for a more economical alternative to the prostaglandins. Beta-blockers do have side effects, so they are contraindicated for patients with overt heart failure, cardiogenic shock, sinus bradycardia, second- or third-degree atrioventricular block, bronchial asthma or history of bronchial asthma, or severe chronic obstructive pulmonary disease or hypersensitivity to any component of a topical beta-blocker.^6,7 However, many people can use them without any problems.

If a patient asks me to prescribe a less expensive glaucoma drop, I talk to him about timolol hemi-hydrate or generic timolol maleate, and we discuss the potential side effects and the need for occluding the punctum while instilling the drops. Then I have him switch therapies to see if we can achieve the same pressure control as we did with the prostaglandin. Often we can.

Assessing efficacy

Switching glaucoma drops is a fairly straightforward process. If a patient has been using bimatoprost (Lumigan; Allergan Inc.) at night for months, for example, I may switch him to timolol hemihydrate either once or twice a day. I instruct the patient to finish the bimatoprost he has at home, then start using the timolol hemihydrate the next morning. Follow-up is usually 6 to 8 weeks for the average open-angle glaucoma patient who has some mild field loss and perhaps some mild nerve damage, and who was fairly well-controlled with his prior therapy.

In my practice, about half of patients make the switch successfully. Interestingly, some of my patients who have switched from a prostaglandin to a beta-blocker have reported an unexpected secondary benefit. They tell me their eyes feel and/or look better than when they were using the prostaglandin.

Switching to a beta-blocker may not be the answer for all patients. If a patient's pressures have been well-controlled on a prostaglandin, but after switching to a beta-blocker, they become less stable or higher than they were, we may consider the following corrective measures:

• Switching back to the prostaglandin
• A laser supplement
• Switching to a generic dorzolamide/timolol combination or brimonidine tartrate/timolol maleate (Combigan; Allergan Inc.), if that is favorable on their tier structure
• Adding a secondary generic agent to the beta-blocker.

Team approach

By its very nature, a glaucoma practice is a chronic disease practice, and if you're so inclined, you can get to know your patients well. That's my approach, and I try to work with my patients within the framework of what they ask me to do. I don't think you can be too dogmatic with these patients and just tell them what to do. I prefer to foster a team approach to take care of their eyes. If we have a good dialogue and patients can tell me what they need, we can sort out their options and the two of us can reach a decision.

In my practice, we strive for a verbal contract with each patient. I'll ask, “If we use this, do you think it will fit within the framework of what you're telling me?” If they say yes, then we have a contract. If they say it's still too expensive, then we look for another solution. I prefer to talk to patients so they can play a role in their therapy. I think this team approach contributes to reasonable adherence and persistency, as long as the other factors, such as side effects and economics, don't get in the way. I've found if you can give patients something they can do and you explain the importance of it, most patients want to comply most of the time.

References

1. Parrish RK, Palmberg P, Sheu WP; XLT Study Group. A comparison of latanoprost, bimatoprost, and travoprost in patients with elevated intraocular pressure: a 12-week, randomized, masked-evaluator multicenter study. Am J Ophthalmol. 2003;135:688-703.
2. Varma R, Hwang LJ, Grunden JW, Bean GW, Sultan MB. Assessing the efficacy of latanoprost vs timolol using an alternate efficacy parameter: the intervisit intraocular pressure range. Am J Ophthalmol. 2009;148:221-226.
3. Stewart WC, Stewart JA, Nelson LA, Kruft B. Physician attitudes regarding prostaglandin treatment for glaucoma in the United States and Europe. Eur J Ophthalmol. 2008;18:199-204.
4. Rylander NR, Vold SD. Cost analysis of glaucoma medications. Am J Ophthalmol. 2008;145:106-113.
5. Fiscella RG, Green A, Patuszynski DH, Wilensky J. Medical therapy cost considerations for glaucoma. Am J Ophthalmol. 2003;136:18-25.
6. Kirwan J F, Nightingale JA, Bunce C, Wormald R. Beta blockers for glaucoma and excess risk of airways obstruction: population-based cohort study. BMJ. 2002;325:1396-1397.
7. Han JA, Frishman WH, Wu Sun S, Palmiero PM, Petrillo R. Cardiovascular and respiratory considerations with pharmacotherapy of glaucoma and ocular hypertension. Cardiol Rev. 2008;16:95-108.