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Allergic Eye Disease: Therapeutic Considerations

Allergic Eye Disease: Therapeutic Considerations. Allergic Therapy. Introduction 35 minute CE presentation given April 2007 Sources: Your journal of choice Review of Optometry 3/15/07 “Ocular Allergy, Find It, Treat It, Code It” “Financial Implications of Treating Allergies”

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Allergic Eye Disease: Therapeutic Considerations

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  1. Allergic Eye Disease: Therapeutic Considerations

  2. Allergic Therapy • Introduction • 35 minute CE presentation given April 2007 • Sources: Your journal of choice • Review of Optometry 3/15/07 • “Ocular Allergy, Find It, Treat It, Code It” • “Financial Implications of Treating Allergies” • “What’s in the Pipeline?” • AH / MCS with vasoconstrictor • Handbook of Ocular Ds Mgmt

  3. Allergic Therapy • Introduction • 50% of US pop suffers from allergy • 80% of these have ocular symptoms • Add 50% of net income by incorporation of allergic therapy in your practice? • 1300 patients/practice with allergy • $118 per 2 visits per year • Assume 15% attrition and 50% return rate • Year 1: $151,807, year 5: 321,120.19

  4. Allergic Therapy • Introduction • Topicals vs Orals • Topicals • More effective • Better therapeutic concentrations at anterior eye surface • Less side effects • Orals: contact dermatitis

  5. Allergic Therapy • Introduction • Rx or OTC Agents • OTC use in general discouraged • Changes our therapeutic relationship: loss of patients • Can increase problems: toxicities • Not really cheaper if patient has insurance • New OTC • Zaditor 1/07 • Alaway

  6. Allergic Therapy • Introduction • Rx or OTC Agents • Did you know? • Most patients self-treat…me too • 50 million OTC products last year • 6 million Rxed products last year (all healthcare providers)

  7. Allergic Therapy • Introduction • Loading dosages • Qid x 2 weeks, then bid prn • Bid x 2 weeks, then qd prn

  8. Allergic Therapy • Introduction • Bottle sizes • Bid: 5 ml • Qid: 10 ml • Of course depends on treatment duration • Optivar cheaper?: 3 and 6 ml bottles

  9. Allergic Therapy • Introduction • Prices and Insurance Coverage • My experience • Tenncare? Missouri insurance coverage • Samples • Expensive co-pays • Walgreen’s on-line • Patanol $93 (5 ml) • Pataday same except 2.5 ml • Alrex $70 (5 ml) $131 (10 ml) • Lotemax 51 (5 ml) $100 (10 ml) • Zaditor or Alaway OTC (5 ml) $14.99

  10. Allergic Therapy • Introduction: a few more things • Easy, accessible, low risk • Patanol is the market leader (65%) • For good reason • Best class • Best agent? • Pataday looking awesome too!

  11. Allergic Therapy • Conditions • Seasonal allergic conjunctivitis • Acute, hay fever, tree pollen • Perennial allergic conjunctivitis • Acute, year round, animal dander • GPC: allergic condition? • Atopic keratoconjunctivitis: restasis option • Vernal keratoconjunctivitis: restasis option • Contact dermatitis • Topicals  orals in general

  12. Allergic Therapy • Differential Diagnosis • Dry Eye • Itching and burning • Blepharitis • Non-allergic conjunctitivitis • Hypersensitivity reactions

  13. Allergic Therapy • Management • Eliminate the agent • Feasible? • Supportive therapy: cold compresses

  14. Allergic Therapy • Management • Topical OTC agents • Remember we usually do not want to recommend these • Non-preserved artificial tears • Decongestants • Antihistamines: Alamast • Antihistamine-decongestants • Antihistamine-mast cell stabilizers: Zaditor

  15. Allergic Therapy • Management • Topical Antihistamines • Emadine (emastadine, Alcon) • Qid for allergy • Great for itching • For lid myokymia: qid x 1 week, then bid x 1-2 weeks • Livostin: as of 12/2004, Novartis stopped production

  16. Allergic Therapy • Management • Topical mast cell stabilizers • No role in acute allergic symptoms • Will eliminate a subsequent allergic response • Visiting a relative • Long term use is safe

  17. Allergic Therapy • Management • Topical mast cell stabilizers • Alamast and Alocril • Alamast (pemirolast, Vistakon) • Qidbid • Alocril (nedocromil, Allergan) • Qidbid

  18. Allergic Therapy • Management • Topical mast cell stabilizers • Alomide, Optichrom, and Crolom • First generation products • Alomide approved for children as young as 2 years old

  19. Allergic Therapy • Management • Topical antihistamine / mast cell stabilizers • Most experts agree… • For most allergic ocular cases, bidprn • For CL wearers, am drop without lenses, pm drop with lenses • For kids as young as 3 years old • Side effects…headache / irritation

  20. Allergic Therapy • Management • Topical antihistamine / mast cell stabilizers • Patanol (olopatadine 0.1%): bid • 5 ml • Pataday (olopatadine 0.2%): qd • Alcon • Recently became available • The only 1x/day topical allergy drug • Studies support its effectiveness x 24h • CL wearers…ideal • 2.5 ml

  21. Allergic Therapy • Management • Topical antihistamine / mast cell stabilizers • Optivar (azelastine, MedPointe) • 3 ml bottle and 6 ml bottle • Cheapest? • Elestat(epinastine, Allergan) • Zaditor (ketotifen, Novartis) • Now OTC

  22. Allergic Therapy • Management • Topical Steroids • For clinical inflammation above and beyond itching I.E. vernal • Safe and very effective for short time periods on most patients • Lots of options…as with all agents…stick with what works for you

  23. Allergic Therapy • Management • Topical Steroids • Alrex (loteprednol 0.2%, B & L) • Suggested: q2h x 2 days, qid x 1 week, bid or qid for another week • Very safe in terms of older ketone-based steroids in terms of ocular side effects • Structurally, the #20-position ketone group is absent

  24. Allergic Therapy • Management • Topical Steroids • Lotemax (loteprednol 0.5%, B & L) • For even more pronounced clinical expression of allergy • FML (flourometholone alcohol, Allergan) • PredForte

  25. Allergic Therapy • Management • Topical Steroid Creams • Aristospan (0.1% triamcinolone acetonide, Sandoz) • Diprosone (0.05% betamethasone dipropionate, Schering) • Elocon (0.1% mometasone furoate, Fulford) • Bid 10-14 days for Contact Dermatitis • Other options?

  26. Allergic Therapy • Management • Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) • Generally not thought of as anti-allergy • Acular is only one approved for allergy • Beneficial effect on ocular itching • Nevanac and Xibrom • More for post-operative prevention of macular edema

  27. Allergic Therapy • Management • Oral Agents: OTC and Rx • Antihistamines • Exacerbate ocular surface dryness, even the non-sedating types • Allegra, Benadryl, Claritin • Zyrtec • Yields therapeutic concentrations at anterior segment?

  28. Allergic Therapy • Management • Oral Agents • Steroids • Medrol dosepak • Contact dermatitis • Methylprednisone (21 4 mg tablets): 6 tabs day 1 and reducing 1 tab each subsequent day • Prednisone • Pred-Pak

  29. Allergy Therapy: Wrap Up • Clinical Pearls for Treating Ocular Allergy • Hx of itching  diagnosis • Cool compresses instead of rubbing • Frequent instillation of preservative-free ocular lubricants? • Rx antihistamine / mast cell stabilizers • Look for corneal involvement • Begin treatment early • Be proactive to improve pt’s quality of life

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