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    Beyond IOP in glaucoma treatment


    Other issues

    Beta adrenergic antagonists present other complications. These agents are less effective when taken at night, compared to daytime dosing. They can reduce blood pressure, exacerbate the symptoms of Alzheimer’s disease, and are a risk factor for falls in the elderly, as well as induce psychological and sexual problems.

    What may be less often recognized is that beta adrenergic antagonists can have an additive effect with systemic beta blockers and lower blood pressure to inappropriate levels. If beta adrenergic blocking agents must be used, dosage should be minimized. Once-daily morning dosing can provide a similar therapeutic effect as a twice-daily regimen that includes nighttime dosing. There is also a relatively high rate of tachyphylaxis with these agents, Dr. Stamper noted. In many cases, stopping the drug altogether has no effect whatsoever on IOP.

    Brimonidine is an important fallback agent, he continued. It is clearly effective at lowering IOP and may offer some degree of neuroprotection. Dr. Stamper said it can be helpful for patients whose glaucoma continues to progress despite showing good IOPs. Brimonidine is also available with a non-BAK preservative, which can make it a good choice for patients with ocular surface problems.

    On the negative side, brimonidine has high rates of hyperemia and allergic reactions. Dry mouth and somnolence are common problems, especially with the higher doses, and there have been questions of safety in young children.

    “People don’t often associate eye drops with problems like dry mouth and sleepiness, but these are two of the more significant side effects of this agent,” Dr. Stamper said. “Just moving from 0.2% to 0.15% gives a much lower incidence of side effects. That reduction is probably even more notable with the 0.1% formulation.”


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