Evolution of the treatment paradigm for maximum medical therapy in glaucoma

Abstract

ABSTRACT Introduction: Glaucoma therapy is typically started with a single drug that is considered most effective for IOP control and is relatively safe. Several classes of agents are available, including prostaglandin analogs (PGAs), β-blockers, carbonic anhydrase inhibitors (CAIs), cholinergic agonists, and α2-agonists. Most patients will require combined therapy to achieve predetermined target intraocular pressure (IOP), which can be difficult to sustain over time. Currently, maximum medical therapy (MMT) in glaucoma refers to ≤3 classes of medications combined to substantially lower IOP. MMT can be achieved using multiple single agents, double, or triple fixed-dose combinations. Areas covered: Several randomized controlled clinical trials demonstrated that 3-drug combination regimens are superior to 2-drug regimens for lowering 24-hour IOP, which may prevent glaucoma progression. However, long-term clinical evidence with 3- or 4-drug MMT regimens is scarce. Expert commentary: The next logical step in evolution of effective MMT may be the use of 4 classes of medications, adding triple fixed-combination to single agent or combining fixed-dose combinations of CAI plus α2-agonist and fixed-dose β-blocker plus PGA. Availability of novel fixed-dose combinations may optimize efficacy, tolerability, adherence, and improve long-term outcomes. Further controlled evidence is required to accurately delineate the value of current and future MMT regimens.