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    Better alternatives to standalone prostaglandin analog therapy


    For example, when a topical carbonic anhydrase inhibitor (CAI) is added to a prostaglandin, the benefits include a good nocturnal IOP-lowering effect, no impact on systemic blood pressure (BP), and a low allergy rate; however, there can be corneal endothelial toxicity.

    The CAIs are better at lowering the IOP when they are used with prostaglandins rather than beta-blockers.

    When considering use of a beta-blocker in addition to a prostaglandin, the important factors are ruling out asthma, emphysema, and bundle branch block; the moderate IOP-lowering efficacy, the possibility for tachyphylaxis, and the limitation of once-daily use in the morning.

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    When combining alpha agonists with prostaglandins, the red flags are the 28% allergy rate (mostly follicular conjunctivitis), contraindicated use in infants and young children and elderly adults, and the effect on the systemic BP (decreased ocular perfusion pressure), according to Dr. Asrani.

    Low diastolic ocular perfusion pressure (DOPP), which is defined as the difference between the diastolic BP and the IOP, he emphasized, is the major risk factor for the genesis and progression of glaucoma.

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    “The DOPP must be kept at about 55 mm Hg. Below that level, it becomes a major risk factor. The prostaglandins and CAIs are the only ones that increase the perfusion pressure,” he said.

    With beta-blockers, the DOPP remains unchanged because the drugs do not work as effectively at night; with alpha agonists the DOPP decreases significantly.

    Another option when a prostaglandin is not as effective as desired is adding a fixed-combination therapy. Dr. Asrani noted that a fixed-combination drug is often used as the initial adjunctive therapy.

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