Topical eye medication: dialogue, drops & directing Professor Chris Purslow

Transcription

1 Topical eye medication: dialogue, drops & directing Professor Chris Purslow PhD, MCOptom, FBCLA Head of Medical Affairs

2 Established in the UK in 2008 Head office at Keele University, Staffordshire Dedicated to OTC eye care and medical & surgical ophthalmology Driving Innovation, Education & Professionalism in Eye Care

3 8 therapy areas OTC, P, POM

4 Preservative free is in our DNA

5 Let s focus

6 What do we think happens in your the community pharmacy?

7 Questions for you. 1. When you dispense/sell eye drops do you ask about application do you know how to apply these? 2. Would it be pharmacist or the support staff? 3. When you carry out an MUR, and eye drops are on the Rx list, do you talk about them?

8 Tricky question.. IS THIS AT ODDS WITH YOUR CONFIDENCE AROUND INHALERS OR ECZEMA?

9 Common eye conditions that you are recommending drops for Allergy Dry eye Infective conjunctivitis Brightening/whitening? CAUTION Contact lens comfort?

10 Common eye conditions that you are dispensing drops for Glaucoma Dry eye Infection Allergy Inflammation

11 LET S THINK FIRST ABOUT GLAUCOMA.

12 Things that may surprise you. No-one at the hospital normally explains the eye medication nor how to use them Their optometrist will ask about them and who they see..but that s it. That leaves you?

13 Adherence in glaucoma is terrible

14 Mrs Jones

15 Persistence with glaucoma treatment Nordstrom BL et al, AJO 2005; 140: Rees G et al, Ophthalmology May;117(5):903-8

16 Why is adherence so terrible? Side effects Squeezing and aiming eye drop bottles Lack of understanding Frequently asymptomatic at diagnosis Not wishing to displease doctor at review appt

17 Dry eye is more likely in glaucoma Rossi et al (2009) Dry eye syndrome-related quality of life in glaucoma patients. Eur Jo Ophthalmol 19(4): Dry eye significantly more likely in glaucoma Controls 5% 1 drop/day 11% 2 drops/day 39% 3 drops/day 40% Dry eye negatively influences QOL even if you have glaucoma

18 TFOS DEWS II 2017 Chronic exposure of the ocular surface to preservatives is now well recognized to induce toxicity and adverse changes to the ocular surface

19 Home Current Issue CME Live Programs Supplements CME online E-Newsletters Calendar of Events C search for... Advanced Search Glaucoma Drugs and The Ocular Surface Research is seeking to understand what additional roles preservatives may serve beyond protecting the medication itself. Staff 11/15/2006 Jess T. Whitson, MD, FACS, Dallas, Dwight L. Varner, PharmD, Downers Grove, Ill., and Peter A. Netland, MD, PhD, Memphis, Tenn. The prevalence of both glaucoma and ocular surface disease, or OSD, is increasing as the population ages. It has been estimated that as many as 20 percent of Americans have some dry-eye symptoms. The prevalence of dry eye increases with age and is most common among postmenopausal women.1,2 Often, the presence of one of these disease states contributes to the symptoms or complications of the other. Glaucoma is a frequent complication in patients with severe OSD.3 In fact, the overall prevalence of glaucoma in these patients is estimated in some studies to be as high as 75 percent.3 Furthermore, many treatment modalities for OSD, such as topical corticosteroids, contribute to the risk of glaucoma or can exacerbate preexisting glaucoma.3 NEWSLETTERS Review of Ophthalmolog Online April 27, , Num. 17 April 20, , Num. 16 April 13, , Num. 15 April 6, V Num. 14 View More Retina Online April Volu 11, Number 4 March Vo 11, Number 3 February Volume 11, Num January Volume 11, Num View More To subscribe to our Chronic use of preservative-containing topical ophthalmic products for the treatment of glaucoma can often contribute to the e-newsletters and re development or worsening of OSD. Many patients with glaucoma have some degree of ocular surface damage. It is estimated them via , clic that dry eye may be present in approximately 40 percent of glaucoma patients.4,5 Glaucoma treatment typically involves the use here. of one or more topical ophthalmic medications for the reduction of intraocular pressure. These medications must be used chronically, resulting in high cumulative exposure to potentially toxic preservatives contained in the product formulation.6 Research demonstrates that signif exposure to glaucoma medications preserved with benzalkonium chloride (BAK) can produce alterations in tear film function and inflammatory conjunctival infiltrates.7 This article will examine the presence of OSD in the glaucoma patient, the role of preservatives in glaucoma medications that are chronically used in these individuals, and the alternative solutions to consider in this setting. OSD in Glaucoma Patients A common complication of OSD is dry eye, which is often caused by tear instability and hyperosmolarity that create a proinflammatory condition. In fact, re evidence indicates that a hyperosmolar environment is itself proinflammatory.8 Although the causes of dry eye are myriad, they tend to share several comm characteristics.

20 Consensus in the literature that BAK is the culprit

21 Up-down sign of eye drop toxicity

22 When the doctor asks, they are fine but.. Even if local adverse events and OSD contribute to glaucoma patient dissatisfaction, only a minority of patients expressed such dissatisfaction.

23 Parallel experience

24 EARLY EXPERIENCES REALLY MATTER.

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27 Where lies the problem? Four major types of barriers to effective adherence in glaucoma: 1. Medication regimen 2. Patient factors 3. Prescriber/dispenser factors 4. Situational or environmental factors

28 Where lies the problem? Four major types of barriers to effective adherence in glaucoma: 1. Medication regimen 2. Patient factors 3. Prescriber/dispenser factors 4. Situational or environmental factors

29 WHAT SIMPLE THINGS CAN WE IMPROVE ON?

30 Starting the right way This treatment is every single day for the rest of your life, like your blood pressure tablets. Your drops are your medication Ask someone to watch you applying the drops You must never run out of your medication You must not forget your medication You must ask if your don t understand

31 Detecting non-adherence (quickly and simply)

32 Top tips for MURs Target those who admit they have missed hospital appointments Assume non-adherence in all Ask as if you know what they might be doing. Have you worked out the best way for you to get your drops in? When did you last use your drops? How many times in an average week do you miss taking your drop(s)? Are you deliberately skipping or just forgetting? Why would you skip it on purpose? What side-effects have you noticed?

33 Communication tips Show empathy with compliance issues but end with firm and serious Consequences of not doing.mention more drops and surgery before talking about vision loss Tell them to talk to the prescriber about the side-effects

34 Have you ever applied eye drops yourself?

35 Supporting Patients How To Put A Drop In The Eye Wash hands before handling the bottle. Open the bottle. Test the pressure required to release a drop. Insert 1 drop in the pocket of the lower eyelid. ALTERNATIVELY: Rest the ridge of the bottle on the bridge of your nose.

36 Battle of the Bottle Connor & Severn (2011) shows that much more force is required for systems like MINIMS, etc.

37 Popper bottles can require forces the same that a Minim does! Normal pinch grip varies with age and gender Normal ranges from 17 to 160N 3-point-pinch norm for older female (eg 55yr old) is 15.7N (2013)

38 Killer question to finish MUR.. Has anyone ever watched you use your glaucoma medication?

39 DRY EYE

40 What is your current product offering?

41 What your patient sees?

42 Thinking about the language we use Try these drops for your dry eyes if they don t bring relief, we can try some others

43 What patients actually hear.. I don t know the difference between these products, so here, try these and see which one works for you.

44 Growing market & Growing problem 1 in 5 UK adults have dry eyes 50% of contact lens wearers are affected Approximately 12.5 million people Current value of the market 72M in UK Increasing 4.9% year on year

45 Who are these 12.5M people? Ageing Post Refractive Surgery Screen Use: phones & tablets Tear Quality CAUSES OF DRY EYE SYMPTOMS Dry environments: office/car Air Con Menopause (treatments) Certain prescription Drugs Arthritis

46 What does your dry eye patient feel? my eyes feel scratchy and gritty My eyes get dry due to my contact lenses I work in an air conditioned office and my eyes get dry by the end of the day my eyes water all the time, particularly when I m in the wind My eyes are always sore by the middle of the day They feel itchy and burny My eyes feel itchy and dry Dry eye is not an eye infection

47 The tear film Three layers Oily top layer to slow down evaporation of watery layer underneath Mucus layer at the bottom

48 Tears are unstable in dry eyes Dry eye sufferer 3 4 seconds Normal Blink seconds

49 WHAT IS THE MOST COMMON TRIGGER FOR DRY EYES?

50 8 out of 10 dry eye problems are related to blepharitis Lemp et al (2012) Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea 31(5):472-8

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52 Who suffers from blepharitis? Can affect all age groups, elderly are most at risk More likely to to be found in people with: Dry skin conditions Scalp Dandruff Dry eye (Acne) Rosacea Atopic conditions (eczema, asthma) Parkinson s Disease Down Syndrome

53 What Does Blepharitis Feel Like? It feels like there is something in my eye, but I can't see anything It is painful to open my eyes in the morning My eyelids look puffy as if I have a cold/hangover/am tired I look like I have been crying I have dandruff around my eyes I ve always got sleep in my eyes My eyes feel itchy and dry

54 Blepharitis How common is it? INFLAMMATION OF THE EYELIDS IS THE MAIN REASON PEOPLE GET DRY EYE 40%of 67% people attending for routine eye examinations have some degree of blepharitis In people over 60 Sources: 1. Lemp MA, Nichols KK. Blepharitis in the United States 2009: a survey-based perspective on prevalence and treatment. Ocul Surf. 2009;7(2 Suppl):S1-S148

55 MODERN DRY EYE MANAGEMENT MEANS.

56 DRY EYE RELIEF for A.L.L. 1. Advice 2. Lids 3. Lubricants

57 Advice - Reducing risk factors Stop smoking Stay hydrated Taking breaks from computer Omega 3 intake

58 Lids need TLC think sensitive skin! WARM to relieve blocked glands MASSAGE to encourage secretion CLEAN to remove skin debris to soothe inflamed lids clean and fresh

59 Modern Eye Lid Cleansing It s simple no baby shampoo! Think like a dermatologist no soap/perfume/parabens

60 Blephaclean CE Bestseller Impregnated with micellar solution Can be used for children from 3 months of age Free from preservatives, parabens, soap and perfumes Suitable to contact lens wearers

61 AND THEN WE COME TO THE LUBRICANTS..

62 STEP 1 CLEANSE Start your routine by cleansing your eyelids with Blephaclean, Blephasol or Blephagel. Advise customers to massage eyelids gently using a vertical stroking motion. STEP 2 PROTECT & HYDRATE Apply Thealoz Duo eye drops for long lasting relief from the symptoms of Dry Eye.

63 So what would you ideal drop for dry eyes look like? Be kind to the ocular surface Protect the ocular surface Mimic the behaviour of the tear film Provide long-lasting relief Easy to use and apply

64 So how to find a dry eye drop that works Choose Preservative Free Choose Hylauronic Acid Choose Bioprotectants Easy to use, economical bottle

65 1. Avoiding Preservatives The dosing of 3+ times per day simply exposes the dry eye to too much preservative, for too long (especially BAK) This applies to glaucoma patients, too decades of drops to come..

66 Why Preservative Free? A key concern of the experts Chronic exposure of the ocular surface to preservatives is now well recognized to induce toxicity and adverse changes to the ocular surface

67 So how to find a dry eye drop that works Choose Preservative Free Choose Hylauronic Acid Choose Bioprotectants Easy to use, economical bottle

68 2: Choose Hyaluronic acid Superior to the old P products Long-lasting stability and thickness to the tear film without viscosity Think like an engineer!! Viscoelastic (pseudo plastic) properties It will mimic the tear film (non-newtonian) Highly moisturising

69 So how to find a dry eye drop that works Choose Preservative Free Choose Hylauronic Acid Choose Bioprotectants Easy to use, economical bottle

70 3: Protect the ocular surface Look for HYPOTONIC formulations Look for ingredients that offer protection for the ocular surface Osmoprotection

71 Trehalose a natural bioprotectant Protects lipids and proteins in cell membranes Used in transportation and conversation of grafts and organs Oocytes in IVF - Significantly improves the protection against freezing stress at - 60 C Applications in pharmaceutical formulations: Lucentis (Novartis) & Avastin (Roche), Herceptin (Roche), Advate (Baxter) (SmPC s) 1. Ohtake et al. Trehalose current use and future applications. J Pharm Sci. 2011;100: Katenz E, et al. Cryopreservation of primary human hepatocytes: The benefit of trehalose as an additional cryoprotective agent. Liver Transpl. 2007;13: Matsumoto et al. Seven consecutive successful clinical islet isolations with pancreatic ductal injection. Cell Transplant. 2010;19: Eroglu et al. Beneficial effect of microinjected trehalose on the cryosurvival of human oocytes. Fertil Steril. 2002;77:

72 Where else do you find Trehalose? Trehalose is used in cosmetics, biology, food supplements, chemistry, transplantation, pharmaceuticals.. But first time in a drop for dry eye Dried selaginella 8 hours after water 24 hours after water The importance of Trehalose A naturally occurring molecule which uniquely protects cells from extremes of heat, cold and dryness.

73 Thealoz Duo UNIQUELY combines two innovative ingredients % Hyaluronic Acid: Hydrate and lubrication for long lasting relief 3% Trehalose: For ocular surface protection against dryness and hyperosmolarity

74 4: Good delivery systems Look for bottles that patients squeeze rather than press the pressure required to dispense eye drops from the press and release systems can be as much as 3x more than that of a softshelled multi-dose squeeze bottle

75 ABAK SYSTEM Preservative Free multi-dose bottle Easy to handle for patients ideal for older and those with dexterity problems 3 x less force required than other preservative free bottles Safe for up to 3 months after opening

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77 How should dry eye drops be used? Dry eye drops provide more effective relief when used at regular intervals, rather than when discomfort is felt (Like the therapeutic approach to chronic pain)

78 HOW TO BALANCE YOUR DRY EYE CATEGORY

79 Evolution: 1 st generation Simple lubricants for dry eyes

80 Evolution: 2 nd generation It s all about staying power..

81 Evolution: 3 rd generation It s all about protection Preserved

82 The Evolution Of Dry Eye Drops 2 nd GENERATION 3 rd GENERATION 1 st GENERATION Most go back to the 1950s They are simple lubricants, and any of these products name end in ellose e.g. Hypromellose all these products are preserved Due to the development of ingredients, this generation that gives the staying power on the surface of the eye but also packaging innovation that enabled us to do multi dose preservative free. This generation provide lubrication, staying power and through new ingredients; protection to the surface of the eye. Thealoz Duo offers this protection, hydration and lubricate in a unique preservative free formulation

83 CASE: Mrs Jones, 76yrs Watery eyes (both) for several years Eyes very sore by end of day Eyelids a bit crusty in mornings Bathing eyelids in cold water brings some relief Medication includes Atenolol and aspirin Has tried hypromellose from the GP Some relief but does not last long How do you know what s better?

84 STEP 1 CLEANSE Start your routine by cleansing your eyelids with Blephaclean, Blephasol or Blephagel. Advise customers to massage eyelids gently using a vertical stroking motion. STEP 2 PROTECT & HYDRATE Apply Thealoz Duo eye drops for long lasting relief from the symptoms of Dry Eye.

85 Preservative-free range for Dry eye and blepharitis Thank you Professor Christine Purslow Head of Medical Affairs, UK & Ireland