Glaucoma Physician spoke with Steven R. Sarkisian Jr., MD, about how using compounded medications can benefit both patients and providers.

Q: How do you frame the conversation around compounded medications when talking with colleagues?

A: When I give lectures about new modalities in glaucoma treatment and interventional glaucoma, I often start by talking about patient compliance with medications. Compliance is always the elephant in the room. We're delusional as healers if we think that there aren't issues with taking medications. The rate of true perfect compliance is probably less than 10%, particularly if patients are on more than one medicine. If patients took their drops perfectly, if the drops didn't have any cost, if they didn't have any side effects, if people didn't have any allergies to medications, and every patient was a responder, we really wouldn't be having this conversation. The bottom line is, even patients you think are taking their drops actually are not, or at least not with perfect compliance.

Every time you add a prescription, compliance drops precipitously. When you go from 1 to 2 medications, it drops precipitously. When you go from 2 to 3, it drops further. With the reality of poor compliance, compounded fixed-combination glaucoma medications have been a godsend to my patients. Two companies are doing this, ImprimisRx and OSRX. I have used both.

Q: What are the specific benefits to patients of using compounded medications?

A: There are benefits to both patient and practice of using compounded medications. Patients are often paying too much for their medications, particularly if they end up being on a Part D plan and falling into the donut hole. Compounded medications offer multiple medicines in one bottle, and patients don't have to use their insurance. They pay cash and it costs less than the copays would be for 3 to 4 bottles of drops. They also don’t have to worry about their insurance every time the company switches its formulary. With every formulary switch, there is a cascade of lost time and revenue with countless phone calls between pharmacies, doctors, and patients, and, worst of all, the risk that the patient might not get their medicine on time waiting for the logistics to work out.

Change starts with the eye doctors and their staff. We have to have this conversation with patients, because patients don’t know this is an option. I ask the patients, “How much are you paying for each medication?” “Most people have trouble remembering to take the second dose of the twice-a-day medicine. How often do you miss that dose?” I have been amazed at what patients tell me.

I often use the timolol 0.5%/brimonidine tartrate 0.2%/dorzolamide 2% (tim/brim/dor) fixed combination and the timolol 0.5%/brimonidine tartrate 0.2%/dorzolamide 2%/latanoprost 0.005% (tim/brim/dor/lat) fixed combination from OSRX (Figure 1). Patients get a morning bottle and an evening bottle, which should last 45 days, mailed to their house. Patients find the idea of a morning and evening bottle very appealing, considering that some might be on 4 different drops, 3 of which are twice a day and 1 of which is once a day. Patients get the schedule confused, and sometimes they have to wait 5 or even 10 minutes between drops, sometimes doing punctal occlusion after each one. Compounded medications free up their time. They love it! Usually, people don’t know what they want until you show it to them.

Our goal is to stop patients from going blind, so we need to be honest about what patients are willing and able to in terms of drop regimen. We're there to make a difference in patients’ lives with every tool that we can, and compounded medications have become really powerful tools to that end.

Q: What are the benefits to the physician and practice?

A: The bottom line is, compounded drops set the doctor and staff free to practice medicine and not waste time and money fighting third parties. This can include phone calls, prior authorizations, a letter of necessity, and at least one phone call from the pharmacy asking if we are sure we can’t switch to a drug on the formulary. And even once the drug is on formulary, it often won't be on a reasonable tier, so then we're dealing with the drug company. For a glaucoma specialist or general ophthalmologist for whom at least 20% of their practice is glaucoma, this philosophy of compounded glaucoma drops sets them free from this burden. It can even reduce the risk of physician burnout.

Q: What is the difference in the amount of preservatives patients are exposed to in branded drugs and compounded drugs?

A: Often, ocular surface disease and glaucoma go together. The preservative benzalkonium chloride (BAK) is very toxic to the cornea, so when you're constantly hitting the cornea with BAK, all you're doing is making their ocular surface disease worse. Moreover, patients can develop medicamentosa after prolonged, repeated exposure to drops with BAK, causing red, severely irritated eyes.

One of the ways of preventing medicamentosa is to combine medicines into one bottle, so you're only hitting the eye with preservatives once or twice a day as opposed to 9 or 10 times. Preservative-free medications are usually not needed in this setting. They have a shorter shelf-life and cost more. The simple the act of switching a patient from 9 drops a day to 1 or 2 drops a day is a healing balm to their red and sore eyes, not to mention an improvement to their quality of life.

Q: What are the barriers to producing or prescribing compounded medications?

A: The great thing about these drops is that they work just as well as the drops in separate bottles, and we can get a variety of combinations. The logistical challenge to producing these compounded drugs revolves around testing, which can be cost-prohibitive if done in small batches. Testing in bulk and then bottling and distributing is the only way to do this, and that's why the two pharmacies currently making these compounded glaucoma drops have been so successful. Because of the cost, local compounding pharmacies can’t really compete.

For physicians, it's very difficult to change once we establish practice patterns. You have to make a real effort to do it. One of my mantras has always been, “Friends don’t let friends be on 4 bottles of eyedrops.” Moreover, my approach to life is to be content but never satisfied, and always being a little uncomfortable. I like doing new things that I've never done before, not just for the sake of doing new stuff, but because I know that I often discover things that are so much better.

It's just a matter of having combination drops in the center of your mind. Any patient using more than one bottle may benefit from combination drops. Often, I'll have patients who are on 2 drops or 3 drops and they're having trouble paying for it. I don’t start a fourth medication; I initiate a discussion about laser, MIGS, or compounded drops. I've saved numerous people from surgery, because many patients just need that little extra IOP lowering to get them to target, but I knew they weren't going to take 4 bottles.

Q: What kind of savings do patients see?

A: Really the full spectrum. They can save hundreds of dollars a month.

Q: Do you combine compounded drugs with branded ones?

A: There are many different combinations of therapies you can implement to keep compliance where it should be. You have to be a little creative.

There are obviously some things for which there's no generic available. There's no Rho kinase inhibitor that can be combined by a compounding pharmacy, and there's some people who can't be on timolol because they have asthma or they have depression or they have other issues. So being able to give people a fixed combination of brimonidine and dorzolamide by themselves might be great. There are some people who have allergies to brimonidine, so having other combinations without that would also help. There are other reasons more important than availability that would make us want to have a variety of combination glaucoma drugs. I have some patients on tim/brim/dor BID and latanoprostene bunod at night, which only comes as branded Vyzulta (Bausch + Lomb). We can redefine what “maximally tolerated medical therapy” is.

It's freeing for the patient, because they don't have to waste half a day making phone calls between their physician and their pharmacy and their insurance company trying to get the medication that the physician wants them to be on. It decreases administrative costs for practices when the administrative costs for private practices has increased hugely in the electronic era.

This has mattered to me as a CEO of a company. This has made a big difference in lowering my administrative costs, and I'm actively trying to switch as many people over to these medications that I can for that very reason, because I know that it's going to be taken care of electronically without red tape. With compounded drops, doctors can finally wrestle back control from “The Man.”