Recommended Therapeutic Flow Chart
For New Glaucoma Patients
- Initiate therapy with Xalatan or Travatan, or Betimol, or
Istalol depending upon two factors: the amount of IOP reduction
needed to reach your target, and cost.
- If the monocular trial of either drug fails to achieve target
IOP, try the other one. If target IOP is achieved, then you’re
finished.
- If these two approaches lowered IOP, but neither reached target
IOP, then try the Betimol or Istalol in the morning, and the
Xalatan or Travatan in the evening. In our experience, this
combination of aqueous suppression and outflow enhancement
achieves target IOP in at least 80% of patients. Do note, however,
that about one-half of all primary care glaucoma/ocular hypertensive
patients achieve target IOP with just one drop of either Betimol
or Istalol, or Xalatan or Travatan daily.
- What if only Betimol or Istalol, or only Xalatan or Travatan,
had a positive therapeutic response, but fell short of target
IOP by 3-4 mm Hg? Try an additive therapeutic trial with either
Rescula or brimonidine. Additive clinical studies indicated
that both of these medicines performed similarly. Since Rescula
has a considerably safer side effect profile, we would select
it initially. If minimal response or target IOP is not reached,
then try brimonidine.
- What if neither Betimol or Istalol nor Xalatan or Travatan
proved effective? Then try brimonidine, since it performs better
than Rescula in monotherapy. If brimonidine fails to achieve
the target IOP, then try Rescula, one of the topical CAIs or
Pilopine HS gel.
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