Beta-blockers not obsolete, but no longer treatment of choice for first-line therapy

San Francisco - Based on a review of efficacy, safety, and compliance issues, Shan C. Lin, MD, now considers a prostaglandin analogue as his drug of first choice for medical treatment of ocular hypertension and glaucoma. For select patients, however, beta-blockers may still be appropriate if the cosmetic side effects of the prostaglandin analogues or their cost present significant obstacles to use.

Data from two recent meta-analyses establish the greater IOP-lowering efficacy of the prostaglandin analogues versus beta-blockers. Furthermore, various studies show that latanoprost is better than beta-blockers in flattening circadian fluctuation of IOP, and it has been shown to be associated with better therapeutic persistence as well, said Dr. Lin, assistant professor of clinical ophthalmology, University of California, San Francisco, and director, glaucoma service, San Francisco General Hospital.

Systemic side effects continue to be a significant concern associated with beta-blockers. Those drugs have the potential to affect heart rate, blood pressure, and bronchial reactivity and can also cause a number of other systemic side effects. For the prostaglandin agents, the main adverse events include iris and skin pigmentation, eyelash growth, and hyperemia, which is usually mild and often transient.

“When prescribing a beta-blocker there is a whole litany of things that we need to explore with our patients and caution them about, whereas for the prostaglandins, I tell my patients the risks are basically cosmetic. However, I do avoid the prostaglandins in patients with a history of cystoid macular edema, uveitis, or herpes virus infection,” Dr. Lin said.

While the prostaglandin agents are more expensive than the beta-blockers, because of prescription medication coverage, cost is not a deciding factor for many patients. However, it is important to ask about co-pays because economics can be a consideration for some patients.