ROCK inhibitor can be used as a first-line or adjunct therapy
This Focus column presents the perspectives of the author who discusses her firsthand experience with the new therapy.
Initiating,managing and maintaining glaucoma medication regimens can be challenging, for both patient and clinician. Medication adherence, progression of disease, surgical interventions, frequent doctor visits and costs can all impact outcomes and strain the delivery system. Compliance improves as more medications are shown to be effective with once daily dosing, such as netarsudil ophthalmic solution 0.02% (Rhopressa, Aerie Pharmaceuticals Inc.).
Rhopressa is a once daily treatment for ocular hypertension and open-angle glaucoma. As a Rho-kinase (ROCK) inhibitor, Rhopressa works to increase trabecular outflow by relaxing the cellular contraction of the trabecular meshwork and decreasing the production of its extracellular matrix, thus decreasing IOP. Rhopressa may act as a first line therapy, particularly for those patients who are intolerant to a prostaglandin analogue, and as an adjunct to any class of glaucoma medications.
Once-daily Rhopressa was shown to be comparable to timolol 0.5% twice-a-day in three Phase 3 trials in open-angle glaucoma and ocular hypertension patients, as seen in Clinical Trial ROCKET 1. The IOP-lowering effect was consistent across a range of baseline pressures and maintained for 12 months. Thus, it is a potent drug of long duration.
The specific ability of Rhopressa to increase outflow facility through the trabecular meshwork in glaucoma patients has been demonstrated in a Phase 2 study, as reported in a recent press release. (Results have yet to be published.)
According to three-month data published in Drugs of Today, common ocular side effects include conjunctival hyperemia (53% in ROCKET 1, 50% in ROCKET 2), cornea verticillata (5% in ROCKET 1, 9% in ROCKET 2), and conjunctival hemorrhage (13% in ROCKET 1 and 15% in ROCKET 2). The majority of these adverse events were mild. There are no known contraindications to using this drug.
I trialed Rhopressa as an adjunct therapy on several patients who were already using multiple medications and were under surgical consideration by glaucoma specialists, secondary to either an increase in IOP, VF progression or both. Hypotensive effect typically ranged from 1 mmHg to 5 mmHg, although some patients experienced a greater effect. About 10% were Rhopressa-intolerant, due to conjunctival hyperemia. Corneal verticillata were noted in a handful of patients after 4-5 months of use.
One patient, in particular, who benefited from Rhopressa is a 60-year-old black gentleman with advanced open-angle glaucoma. This patient was using maximum medical therapy for his right eye, had undergone selective laser trabeculoplasty in both eyes and a trabeculectomy in his left eye. IOPs were 28 mmHg OD and 24 mmHg OS. Rhopressa OU was prescribed with a successful decrease in IOP ranging from 13 mmHg to 17 mmHg at subsequent visits. The patient complained of redness at the initiation of the therapy, which resolved after a few weeks. In this case, Rhopressa is delaying a second visit to the operating room, although its long-term efficacy in this situation remains to be determined.
When prescribing Rhopressa or any ocular medication, discuss with the patient its ocular effects and safety profile. Stress adherence to the Rhopressa regimen of daily dosing at night to maximize efficacy with the least amount of ocular side effects. Scheduling two to three follow-ups at various times of day to check IOP is good practice to have the best idea of the drug’s effect on individual patients. OM