OCULAR ALLERGY INSIGHTS … SPONSORED BY ISTA PHARMACEUTICALS

Treating Ocular Allergies in a Busy Refractive Surgery Practice

Learn the factors that come into play when choosing a therapy to treat ocular allergy symptoms in patients with prior refractive surgery

By Mitchell A. Jackson, MD, Chicago

As an allergy sufferer, I empathize with my patients who come to my office with itching, tearing, watery eyes, hyperemia, conjunctival swelling, burning, stinging and eyelid edema associated with allergic conjunctivitis. If they also have had prior LASIK or PRK, as most of the ocular allergy patients I see have, I know there are certain factors I must keep in mind when choosing a therapy. In this article, I'll outline my approach to treating ocular allergies in these patients.

Therapeutic considerations

By the time we see patients suffering from ocular allergy, most have already tried over-the-counter remedies, including oral antihistamines and/or a variety of topical drops. Not only have these patients not achieved adequate relief of ocular itching but they also may have experienced the drying side effects typical of some oral antihistamines. If they already have dry eye or are predisposed to it by other conditions, including prior LASIK or PRK,¹ they definitely want a treatment that does not exacerbate dry eye. This is a particularly important consideration for patients with perennial allergies, who may use oral and/or topical medicines year round, because they risk developing secondary dry eye over time.

Many patients decide to undergo refractive surgery in the first place because they cannot wear contact lenses comfortably. This contact lens intolerance could be related to underlying dry eye or to ocular allergy.

Whether or not the dry eye is secondary to prior refractive surgery, patients with dry eye may be more susceptible to ocular allergy as a result of tear film abnormalities and may experience greater discomfort from allergic conjunctivitis and topical allergy treatments. So it is important to be aware of allergy and dry eye in all of your patients and crucial that you select a comfortable allergy therapy that won't exacerbate dry eye.

Why Bepreve®?

Bepreve (bepotastine besilate ophthalmic solution) 1.5% (ISTA Pharmaceuticals, Inc.) is indicated for the treatment of itching associated with the signs and symptoms of allergic conjunctivitis.² Bepreve has high H1 receptor specificity³ with low affinity for other receptors (particularly muscarinic) associated with dry eye, dry mouth and drowsiness. It is also an effective mast cell stabilizer that prevents further histamine release.

In clinical trials, Bepreve demonstrated an excellent safety and comfort profile. In a 6-week safety study, eye irritation was not statistically significant (4.7% vs. 2.4% for placebo).⁴ It is also noteworthy that Bepreve was associated with less dry eye than placebo in this study (1.0% vs. 1.7%), suggesting that it is a good choice if existing dry eye is a concern.⁴ In fact, none of the patients in the two efficacy studies reported dry eye.⁵

The most commonly reported adverse reaction in clinical trials was mild taste following instillation in 25% of subjects. We should be aware of this effect and discuss it with patients who are taking Bepreve for the first time. No one in the clinical trial — and none of my patients to date — discontinued the drug because of the taste.⁵ Other adverse reactions reported in 2-5% of patients in clinical trials included eye irritation, headache and nasopharyngitis. From an efficacy standpoint, Bepreve worked rapidly in the trials, with 95% of treated eyes achieving clinically significant relief of ocular itch at onset of action (average of 3, 5, 7 minutes), and produced a durable response lasting at least 8 hours after dosing.⁵ I have observed both of these outcomes in my patients. Most allergy patients suffer throughout the day, so we need to prescribe a therapy that is fast and long-acting. Furthermore, Bepreve was rapidly effective against severe itch in these studies, with 68% of patients reporting complete relief (0 itch) of their severe symptoms at 3 minutes compared to only 3% of patients on placebo drops. This large difference between active and placebo is impressive and gives me confidence that even my patients with profound itch will get rapid, complete relief.⁶

Compliance and cost

Like some other medications for allergy, whether they are nasal sprays, inhalers or systemic drugs, Bepreve is indicated for B.I.D. dosing. I have found that my patients do not "cheat" and use Bepreve more often than indicated as they do with other drops, which increases the cost of therapy because they run out of drops sooner. I believe their compliance is directly related to Bepreve's efficacy and durability.

Bepreve also costs less than the other prescription allergy drops. For example, a single copay covers one 10 mL bottle of Bepreve, which, when used as directed, lasts 60 days. The other prescription allergy drops are available in 5 mL bottles for B.I.D. dosing or 2.5 mL bottles for q.d. dosing (each is a 30-day supply). Patients receive twice as much Bepreve for a single copay, which is a win-win for the budget-conscious.

Safe, effective relief

I have found Bepreve to be a highly effective therapy for treating the ocular itch associated with seasonal or perennial allergies in all my patients, including those who have undergone refractive surgery. Patients experience fast relief that lasts. In my opinion, however, the fact that Bepreve does not seem to exacerbate dry eye in clinical practice — as we'd expect because of its H1 receptor specificity — makes it a good choice for treating ocular itch in patients who also may have dry eye.

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Mitchell A. Jackson, MD, is medical director of Jacksoneye, with offices covering the North Chicago, Lake Villa, Gurnee, and Waukegan areas.

References

1. Ang RT, Dartt DA, Tsubota K. Dry eye after refractive surgery. Curr Opinion Ophthalmol. 2001;12:318-322.
2. Bepreve. Ista Pharmaceuticals®, Inc. Package Insert.
3. Kato M, Nishida A, Aga Y, et al. Pharmacokinetic and pharmacodynamic evaluation of central effect of the novel antiallergic agent bepotastine besilate. Arzneimittelforschung. 1997;47(10):1116-1124.
4. Data on file. CL-SAF-0405071-R. ISTA Pharmaceuticals®, Inc.
5. Data on file. NDA 22-288. ISTA Pharmaceuticals®, Inc.
6. Clark JC, Williams JI, Gow JA, Abelson MB, McNamara TR, for the Bepotastine Besilate Ophthalmic Solutions Clinical Study Group. Bepotastine besilate ophthalmic solution 1.5% rapidly eliminates ocular itching in more severely allergic subjects in the conjunctival allergen challenge model of allergic conjunctivitis. Poster presented at: 24th Annual Eastern Allergy Conference; May 6-9, 2010; Palm Beach, FL.