At Issue

Panelists choose both branded, compounded agents for cataract surgery patients

"At Issue" asked clinicians: In balancing a swift and comfortable postop experience with patient expense, what do you prescribe for your cataract therapeutic regimen?

Integrating compounded agents

Maynard L. Pohl, OD, FAAO: My personal clinical mission in the perioperative care I provide is to strive for excellence in helping to meet each patient’s visual expectations after surgery. Additional measures taken to enable a patient experience that has high value means maintaining a superior quality while reducing cost to the patient. Certainly, this fundamental should apply when it comes to arranging a patient’s cataract postoperative medications.

Maynard L. Pohl

In our comanagement-based consultation and ambulatory surgical centers, we have started integrating the prescribing of high-quality combination eye drop medicine formulations that incorporate the FDA’s manufacturing regulations and guidelines for safeguarding the efficacy and safety of these compounded medications. Our typical postcataract surgery regimen is Pred-Gati-Brom (prednisone acetate 1%, gatifloxacin 0.5%, bromfenac 0.075%, Imprimis), one drop four times daily until gone (3.5 mL). With an abnormal postoperative course requiring additional topical anti-inflammatories, Pred-Brom may be prescribed.

During nearly 3 decades of comanaged cataract patient care experience, my patients initially were provided the luxury opportunity to receive their topical medications at no cost to them. At times they were an antibiotic-steroid combination drop, but then separate bottles soon followed for a period of time. Thereafter, during the evolution of EHR, separate bottles continued although prescribed electronically through traditional pharmacies, which remains an option for patients with reasonable insurance coverage and/or without pharmacy issues. Then, dropless or injectable medications were added to our regimen for suitable candidates, although with an occasional outcome not complication-free and being visually detrimental to the patient. So, in the quest of serving patients with a highly safe, user-friendly, cost-friendly, patient-compliant postoperative medication regimen that has high value, I believe we are on track.

Disclosure: Pohl reported no relevant financial disclosures.

Use of compound drops is a win-win

Cecelia Koetting, OD, FAAO: With our postoperative cataract patients we use a topical steroid, a topical antibiotic and a topical NSAID. We recognize the importance of all three components to decrease risk of postsurgical complications. In the past we had patients who were using a regimen of all generics, all branded drops or a combination thereof. We found that it was difficult for patients to be compliant with all three separate medications, and cost was often a factor.

Approximately 1.5 years ago, our practice decided to switch to a compounded topical postoperative medication for our cataract surgeries. This was an effort to increase patient compliance, decrease confusion and decrease cost to the majority of our patients. Since then we have found an improved rate of compliance and fewer complaints of cost among patients. This has been beneficial both for the practice and the patients. We have had significantly fewer calls regarding drop questions and refill requests. The practice has also noted a decrease in overall chair time with patients and persistent postoperative inflammation.

Cecelia Koetting

Patients have also benefited in the drops costing a consistent $40 for medication per eye. Previously we had patients’ costs of drops ranging from as low as $0 for those receiving medication from the local military base, to upwards of $300 to $400. For those patients who have military-based insurance we allow them to make the decision of paying out of pocket for the compounded medication vs. going to the base where it is often covered. Many still elect to use the compounded drop for the convenience of only having to use one drop. The other benefit to patients is they have had less persistent inflammation and no increase in postoperative cystoid macular edema (CME) in comparison to previous calculations based on the use of three separate medications.

Overall we have found a great win for both clinic and patient with the use of compound drops and plan to continue in this direction.

Disclosure: Koetting reports no relevant financial disclosures.

Switch to brands reduced adverse events

Sarah Klein, OD, FAAO: To reduce the incidence of postoperative inflammation and cystoid macular edema, and to promote fast healing, we have adopted the use of Vigamox (moxifloxacin, Alcon) four times daily for a week and ketorolac and Durezol (difluprednate, Novartis) on a 4-2-2-1 taper over the first month as our go-to antibacterial and anti-inflammatory regimen following cataract surgery. Since switching from generic prednisolone last year, we have seen a decreased incidence of both rebound iritis and CME.

Sarah Klein

Although formulary availability is always a challenge with brand-name medications, we have seen the benefit of the switch to Durezol and have tried to stick to it whenever possible. We’d love to go to a once- or twice-a-day NSAID, but cost is almost always prohibitive. We distribute detailed, charted eye drop instructions to do our best to minimize patient confusion with the regimen, which can be daunting for some people.

As “dropless” cataract surgery has not yet been adopted by our surgeons, for various reasons, we can say that outcomes are generally great, and our patients are thrilled with their results. In this day and age, expectations are higher, and we do what we can to meet them. I very rarely see CME or rebound inflammation and, if I do, it’s usually a poorly controlled diabetic or someone who is frankly not adherent to the drop schedule.

Disclosure: Klein reports no relevant financial disclosures.

Surgeons use traditional and compounded regimens

Karen P. Skvarna, OD: The surgeons in our practice each have his or her own regimen that can change if generics are introduced or if the patient has any allergies. We have about 15 different permutations.

One regimen involves prescribing Polytrim (polymyxin B and trimethoprim, Allergan) four times daily for 3 days before surgery and 1 week afterwards. In addition, the NSAID Prolensa (bromfenac ophthalmic solution 0.07%, Bausch + Lomb) is prescribed once daily 3 days before surgery and 3 weeks afterwards, and Pred Forte (prednisolone acetate, Allergan) is prescribed four times daily 3 days preoperatively and 4 weeks postoperatively. One of our surgeons is strongly against generic ketorolac, saying it damages the cornea.

Karen P. Skvarna

Another regimen involves prescribing Bromsite (bromfenac ophthalmic solution 0.075%, Sun Pharma) instead of Prolensa twice daily 3 days before and 3 weeks after surgery and Durezol instead of Pred Forte, twice daily 3 days before and twice daily for 1 week postop, daily for 2 weeks, then every other day for 1 week.

A third regimen involves prescribing the compounded medication Pred-Gati-Brom four times a day 3 days before surgery, the day of surgery and 1 week postop. Then Pred-Brom is prescribed four times a day for the second week postop, three times a day for the third week postop and twice a day for the fourth week. Patients are given a 2-page checklist indicating when each drop should be taken, with a box to check after they take each dose.

Disclosure: Skvarna reports no relevant financial disclosures.

Integrating compounded agents

Maynard L. Pohl, OD, FAAO: My personal clinical mission in the perioperative care I provide is to strive for excellence in helping to meet each patient’s visual expectations after surgery. Additional measures taken to enable a patient experience that has high value means maintaining a superior quality while reducing cost to the patient. Certainly, this fundamental should apply when it comes to arranging a patient’s cataract postoperative medications.

Maynard L. Pohl

In our comanagement-based consultation and ambulatory surgical centers, we have started integrating the prescribing of high-quality combination eye drop medicine formulations that incorporate the FDA’s manufacturing regulations and guidelines for safeguarding the efficacy and safety of these compounded medications. Our typical postcataract surgery regimen is Pred-Gati-Brom (prednisone acetate 1%, gatifloxacin 0.5%, bromfenac 0.075%, Imprimis), one drop four times daily until gone (3.5 mL). With an abnormal postoperative course requiring additional topical anti-inflammatories, Pred-Brom may be prescribed.

During nearly 3 decades of comanaged cataract patient care experience, my patients initially were provided the luxury opportunity to receive their topical medications at no cost to them. At times they were an antibiotic-steroid combination drop, but then separate bottles soon followed for a period of time. Thereafter, during the evolution of EHR, separate bottles continued although prescribed electronically through traditional pharmacies, which remains an option for patients with reasonable insurance coverage and/or without pharmacy issues. Then, dropless or injectable medications were added to our regimen for suitable candidates, although with an occasional outcome not complication-free and being visually detrimental to the patient. So, in the quest of serving patients with a highly safe, user-friendly, cost-friendly, patient-compliant postoperative medication regimen that has high value, I believe we are on track.

Disclosure: Pohl reported no relevant financial disclosures.

PAGE BREAK

Use of compound drops is a win-win

Cecelia Koetting, OD, FAAO: With our postoperative cataract patients we use a topical steroid, a topical antibiotic and a topical NSAID. We recognize the importance of all three components to decrease risk of postsurgical complications. In the past we had patients who were using a regimen of all generics, all branded drops or a combination thereof. We found that it was difficult for patients to be compliant with all three separate medications, and cost was often a factor.

Approximately 1.5 years ago, our practice decided to switch to a compounded topical postoperative medication for our cataract surgeries. This was an effort to increase patient compliance, decrease confusion and decrease cost to the majority of our patients. Since then we have found an improved rate of compliance and fewer complaints of cost among patients. This has been beneficial both for the practice and the patients. We have had significantly fewer calls regarding drop questions and refill requests. The practice has also noted a decrease in overall chair time with patients and persistent postoperative inflammation.

Cecelia Koetting

Patients have also benefited in the drops costing a consistent $40 for medication per eye. Previously we had patients’ costs of drops ranging from as low as $0 for those receiving medication from the local military base, to upwards of $300 to $400. For those patients who have military-based insurance we allow them to make the decision of paying out of pocket for the compounded medication vs. going to the base where it is often covered. Many still elect to use the compounded drop for the convenience of only having to use one drop. The other benefit to patients is they have had less persistent inflammation and no increase in postoperative cystoid macular edema (CME) in comparison to previous calculations based on the use of three separate medications.

Overall we have found a great win for both clinic and patient with the use of compound drops and plan to continue in this direction.

Disclosure: Koetting reports no relevant financial disclosures.

PAGE BREAK

Switch to brands reduced adverse events

Sarah Klein, OD, FAAO: To reduce the incidence of postoperative inflammation and cystoid macular edema, and to promote fast healing, we have adopted the use of Vigamox (moxifloxacin, Alcon) four times daily for a week and ketorolac and Durezol (difluprednate, Novartis) on a 4-2-2-1 taper over the first month as our go-to antibacterial and anti-inflammatory regimen following cataract surgery. Since switching from generic prednisolone last year, we have seen a decreased incidence of both rebound iritis and CME.

Sarah Klein

Although formulary availability is always a challenge with brand-name medications, we have seen the benefit of the switch to Durezol and have tried to stick to it whenever possible. We’d love to go to a once- or twice-a-day NSAID, but cost is almost always prohibitive. We distribute detailed, charted eye drop instructions to do our best to minimize patient confusion with the regimen, which can be daunting for some people.

As “dropless” cataract surgery has not yet been adopted by our surgeons, for various reasons, we can say that outcomes are generally great, and our patients are thrilled with their results. In this day and age, expectations are higher, and we do what we can to meet them. I very rarely see CME or rebound inflammation and, if I do, it’s usually a poorly controlled diabetic or someone who is frankly not adherent to the drop schedule.

Disclosure: Klein reports no relevant financial disclosures.

PAGE BREAK

Surgeons use traditional and compounded regimens

Karen P. Skvarna, OD: The surgeons in our practice each have his or her own regimen that can change if generics are introduced or if the patient has any allergies. We have about 15 different permutations.

One regimen involves prescribing Polytrim (polymyxin B and trimethoprim, Allergan) four times daily for 3 days before surgery and 1 week afterwards. In addition, the NSAID Prolensa (bromfenac ophthalmic solution 0.07%, Bausch + Lomb) is prescribed once daily 3 days before surgery and 3 weeks afterwards, and Pred Forte (prednisolone acetate, Allergan) is prescribed four times daily 3 days preoperatively and 4 weeks postoperatively. One of our surgeons is strongly against generic ketorolac, saying it damages the cornea.

Karen P. Skvarna

Another regimen involves prescribing Bromsite (bromfenac ophthalmic solution 0.075%, Sun Pharma) instead of Prolensa twice daily 3 days before and 3 weeks after surgery and Durezol instead of Pred Forte, twice daily 3 days before and twice daily for 1 week postop, daily for 2 weeks, then every other day for 1 week.

A third regimen involves prescribing the compounded medication Pred-Gati-Brom four times a day 3 days before surgery, the day of surgery and 1 week postop. Then Pred-Brom is prescribed four times a day for the second week postop, three times a day for the third week postop and twice a day for the fourth week. Patients are given a 2-page checklist indicating when each drop should be taken, with a box to check after they take each dose.

Disclosure: Skvarna reports no relevant financial disclosures.