we encounter inflammatory disease with a confirmed or questionable underlying infective
component. It may be that we are simply concerned about development of infection
when prescribing a steroid. Blepharitis, keratoconjunctivitis, chalazia and inflammatory
stages of microbial keratitis are just a few instances in which a combination antibiotic/steroid
medication is optimal for effective treatment.
Unless the situation mandates the
use of a fourth generation fluoroquinolone as an adjunct to a steroid, TobraDex
remains the "go-to" drug for our profession.
is a tobramycin/dexamethasone combination.
Efficacy and safety
combination, has a well-accepted effective aminoglycoside that addresses the
typical bacteria that we encounter in
eyelid disease and the other entities for which I would use this drug. Tobramycin
is most effective against gram-negative bacteria, especially Pseudomonas, but it
is also effective against most gram-positive bacteria.
For short-term use, this drug is
an excellent cost-effective choice for killing bacterial ocular pathogens, in combination
with its steroid counterpart. Rarely is it used long enough to produce any significant
side effects, unless the patient is pre-sensitized. Although a fourth generation
antibiotic/steroid combo might be a good alternative, none are marketed to date.
The steroid is usually the main component
that I am interested in when prescribing TobraDex. Poorly controlled inflammation
may lead to significant ocular damage, so my goal in using a combination drug is
to knock-out inflammation. Two recent studies, presented at ARVO 2005, prove the
efficacy of dexamethasone. The first concluded that dexamethasone was more effective
than loteprednol at reducing neutrophil release, a key component of the inflammatory
cascade. The other found that tobramycin/dexamethasone significantly decreased the
clinical signs of inflammation when compared with tobramycin/loteprednol.
tobramycin/dexamethasone demonstrated clinically and
statistically significant improvements in the total ocular surface scores when compared
with tobramycin/loteprednol. Having appreciated excellent patient responses to TobraDex
and its history of documented efficacy, this proven drug is a "no-brainer" to prescribe
in my practice. Considering that I use steroid combination drugs for short-term
treatment, my concern about steroid responder issues is minimal and certainly not
a reason to use a different steroid. It's well-documented that it can take three
to five weeks before a steroid responder will demonstrate a rise in IOP, well after
the duration of therapy when I prescribe TobraDex.
Another consideration is availability.
Most third party carriers cover TobraDex. Every time I prescribe a drug that is
not on the patient's formulary, I spend time on the phone with the patient, pharmacy
and/or carrier. It is time poorly spent. TobraDex is also safe and approved down
to two years of age and conveniently available in both ointment and drop formulations.
We have had the luxury of transitioning
from the days of Blephamide to the "Gold Standard" of TobraDex. A time-tested and
proven formulation, it is my first choice when selecting a combination drug for
my patients. I see no scientific evidence to dispute its success or a compelling
reason to jump ship. If the diagnosis is appropriate to treat with a
combination antibiotic/steroid, TobraDex should be your drug of choice.
Corbin is in private group practice. He serves on the Adjunct Faculty at
Pennsylvania College of Optometry and lectures nationally.
Optometric Management, Issue: June 2005