Optimizing Treatment Strategies for Glaucoma Beyond First Line - Episode 10
Panelists discuss the role of rho kinase inhibitors in glaucoma management respective to cost, efficacy, and ease of use.
Neil Minkoff, MD: There are the newer classes of therapies. The rho kinase [rho-associated protein kinase inhibitor, or ROCK inhibitor] class was mentioned earlier. That seems to be the new kid on the block. I was hoping that our 2 prescribing clinicians could enlighten us about what’s good about it or are there any cons? From a managed care point of view or from a patient point of view, there might be a tiering cost or a cost-share problem but in terms of the clinical ramifications.
Terri-Diann Pickering, MD: The netarsudil [Rhopressa] is exciting. It’s the first new agent we’ve had in a long time, and it has a novel mechanism of action at a completely different receptor, the rho kinase receptor, which means that you can add it on to a patient who you presume we previously considered was already on maximum eye drop therapy. In certain individuals I’ve seen a dramatic drop in pressure. That’s a win. Any time we can save a patient from going to the operating room, that’s helpful. That’s the advantage. The huge advantage is it’s once a day, including the fixed combination. It’s once a day, it’s easy to add on even if it’s already being added to a complex regimen and that helps with adherence.
Some of the cons are that they’re not covered on a lot of plans yet because they’re relatively new. The other cons are that patients can develop allergies and adverse effects. The hyperaemia can be quite impressive and long lasting. It has a couple unique adverse effects that none of the other classes have. Some patients can develop corneal opacities, and some can develop hemorrhages on their conjunctiva, and they recur. It’s a heartbreak, these 2 medications can be very effective, they work well, but then you have to stop them because of adverse effects. I don’t know if Dr Radcliffe has had a different experience.
Nathan Radcliffe, MD: No. I’ve had precisely the same experience. You have some patients who, for the first time in their life, their pressure is under control and it’s a lifesaver. Then the next patient will tell you they threw it in the trash after they put it in their eye twice because they’ve never seen their eye that red. But that’s exactly what we need, options that work differently and save some people, and they’re not for everyone. One of the interesting lessons in terms of coverage that I learned is that a new class of medication often comes in with pretty good coverage. And I was able, with prior authorizations, to get my very sick glaucoma patients on Rhopressa with a PA [prior authorization] almost every time. Wow, this is amazing!
Then the fixed combination latanoprost [Xalatan]/Rhopressa comes and I’m thinking this is going to be great because it’s an even better drop, but the coverage wasn’t the same because the mindset of the insurer was we’ll just put them on latanoprost, and we’ll cover the Rhopressa. And I’m thinking I know they cost the same to manufacture, the price is the same, just cover the Rocklatan [netarsudil/latanoprost], which is the fixed combination of latanoprost. But that was much slower, 2 years longer to get the similar coverage that Rhopressa, the single agent, had on day 1. It’s a pretty good example of the discrepancy between how we think and what we are looking for and how things work in the real-world with splitting vs using a fixed combination.
Neil Minkoff, MD: Do either of the payors have any strong thoughts about this new class of medications, the rho kinases? And are they being more aggressively managed?
Maria Lopes, MD, MS: I can start. It’s exactly what Dr Radcliffe said. At the very least, they’re going to be on a higher cost-share tier, in my experience, and not a specialty tier because these are around $300 per month. But they’ll be in a tier 3 with a cost share that’s going to be significantly higher. Usually, the norm is also quantity limits per month. If patients run out of drops, unfortunately they’re going to have to pay an additional copay. In reviewing the Rhopressa at our P&T [Pharmacy and Therapeutics], my recollection is it takes a few weeks, several weeks for it to work. It’s not as quick onset of action. The convenience, the adverse effects were also brought up, as Drs Pickering and Radcliffe mentioned.
But then the issue with latanoprost, the minute you go into a fixed-dose combination, we think of the generic backbone and automatically think this is convenience until proven otherwise. Important I think to sort of highlight that what is the advantage, if you will, the clinical efficacy that it’s not just about convenience, it’s about adherence and adherence is what’s driving the better outcomes.
Kevin Stephens, Sr., MD: I agree 100% with Dr Lopes. We have a big problem, and then that’s why we have to look carefully at the dosing and the therapy, because the costs are considered and we follow the guidelines, and there typically is some type of a rubric. It can be quite a challenge.
Transcript edited for clarity.