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Editors Selection IGR 12-3

Medical Treatment: Nocturnal efficacy of drugs

Comment by Kuldev Singh on:

25447 24-hour intraocular pressure in glaucoma patients randomized to receive dorzolamide or brinzolamide in combination with latanoprost, Ishikawa S; Nakamura Y et al., Clinical Ophthalmology, 2009; 3: 395-400

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While topical carbonic anhydrase inhibitors, now in commercial use for over fifteen years, have been somewhat disappointing stand-alone first line agents for lowering intraocular pressure, the use of this class adjunc - tively with prostaglandins has been surprisingly beneficial and has resulted in a partial paradigm shift in the algorithm of glaucoma care. There are several reasons for this phenomenon. Unlike the beta-blocker class, the use of which is associated with greater efficacy in the diurnal than the nocturnal period, the topical carbonic anhydrase inhibitors appear to work approximately equally well during the day and night, both with monotherapeutic use, as well as adjunctively with prostaglandins as demonstrated in the paper by Nakamura et al. (147). The investigators opted to use two different dosing regimens for one topical carbonic anhydrase inhibitor while only one regimen was used for the other. Using either one or both dosing regimens for each of the two agents would likely have been the more appropriate experimental design, but this would have required enrolling a greater number of subjects in the latter scenario where two doses were compared. Given the small sample size in each of the treatment groups, the power to detect a difference in the IOP lowering between groups is likely not large. Thus the greatest value of the work is to show that collectively, the topical carbonic anhydrase inhibitor class appears to be a useful adjunct to prostaglandin analogues. A larger study would be required to adequately assess differences in efficacy and safety within the class.

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