Abstract
Purpose :
To evaluate the impact of the addition of netarsudil compared to brimonidine in glaucoma patients requiring more than two baseline glaucoma medications for intraocular pressure management.
Methods :
A chart review was performed to compare eyes prescribed with netarsudil (n=176) and eyes prescribed with brimonidine (n=193) as a third to fifth agent in the setting of uncontrolled IOP. Five sequential IOP measurements were obtained to determine the mean change in IOP before and after treatment (ΔIOP = mean IOP4,5 – mean IOP1,2,3). A multilevel linear mixed-effects model assessed the impact of medication (independent variable) on ΔIOP (dependent variable). Additional independent variables of interest included the number of glaucoma medications at baseline, age, sex, glaucoma type and severity, race, and pre-treatment IOP. Multiple linear regression estimated the effect of both medications as a third to fifth agent. Bootstrap analysis was performed to remove sampling bias and equate the distributions of potentially confounding variables for both netarsudil and brimonidine.
Results :
The unadjusted mean ΔIOP for netarsudil and brimonidine was −2.20 and 0.60 mmHg respectively (p < 0.001). The linear mixed-effects model showed that netarsudil significantly improves IOP by 2.30 mmHg more than brimonidine. However, bootstrap analysis revealed both medications demonstrated statistically similar benefits. Both the mixed-effects model and bootstrap analysis showed diminishing effects of both medications with an increasing number of other glaucoma medications at baseline, albeit this trend was not significant in the mixed-effects model. Specifically, the multiple linear regression model revealed the estimated ΔIOP of netarsudil and brimonidine when added as a third, fourth, and fifth agent is −3.18, −2.49, and −1.79 mmHg; and 0.13, 0.82, and 1.51 mmHg, respectively. Both medications failed to control IOP at similar rates, leading to additional laser and surgical interventions in subsequent follow-up in approximately a third of eyes.
Conclusions :
When escalating pharmacologic therapy, netarsudil and brimonidine are comparable options in terms of efficacy. Both medicines have diminishing effectiveness when added in eyes with more glaucoma medications at baseline. Clinicians should consider individual costs and tolerance when deciding the most appropriate treatment.
This abstract was presented at the 2022 ARVO Annual Meeting, held in Denver, CO, May 1-4, 2022, and virtually.