Can a patient be treated concurrently with latanoprost and Rhopressa (netarsudil)?

Yes, a patient can be on both latanoprost and Rhopressa (netarsudil) concurrently.

Concurrent use of latanoprost and netarsudil is explicitly supported and recommended when monotherapy fails to achieve target intraocular pressure (IOP). The combination provides superior IOP reduction compared to either medication alone through complementary mechanisms of action 1.

Mechanism and Rationale

The combination works through dual pathways:

• Latanoprost (prostaglandin analog): Enhances aqueous outflow primarily through the uveoscleral pathway
• Netarsudil (Rho kinase inhibitor): Increases trabecular outflow, decreases episcleral venous pressure, and reduces aqueous production 1

This complementary mechanism explains why adding medications from different classes is appropriate when initial therapy is insufficient 1.

Evidence for Combination Therapy

The combination demonstrates clinically meaningful additional IOP reduction:

• Netarsudil + latanoprost reduces IOP by an additional 1.3-2.5 mmHg compared to latanoprost alone 2
• Netarsudil + latanoprost reduces IOP by an additional 2.66 mmHg compared to netarsudil alone 3
• At 4 weeks, the combination achieved 2.36 mmHg greater reduction than latanoprost monotherapy (p<0.0001) 4

Administration Guidelines

Critical timing requirement from FDA labeling:

• Administer each drug at least 5 minutes apart if using separate bottles 5, 6
• Both medications should be dosed once daily in the evening 5, 6
• A fixed-dose combination product (netarsudil/latanoprost FDC) is available, eliminating the need for separate administration

Safety Considerations

The safety profile of combination therapy is consistent with each component individually 7:

• Conjunctival hyperemia is the most common adverse effect (53-64% with combination) 4, 2
• Most adverse events are mild and transient 3
• Discontinuation due to hyperemia occurs in approximately 7% of patients 2
• No serious adverse events specifically attributed to the combination have been reported 4, 3

Common Pitfalls to Avoid

1. Do not use twice-daily dosing - this is not well tolerated and not recommended per FDA labeling 5
2. Do not combine multiple prostaglandins - using two or more prostaglandins together is contraindicated as it may paradoxically elevate IOP 6
3. Monitor for epithelial corneal edema if the patient has pre-existing corneal stromal edema or compromised endothelial function 5
4. Remove contact lenses before instillation and wait 15 minutes before reinsertion 5

Clinical Algorithm

When latanoprost monotherapy fails to achieve target IOP:

1. Verify adequate adherence and proper administration technique
2. Add netarsudil (either as separate drop 5 minutes apart, or switch to fixed-dose combination)
3. Reassess IOP at 2-4 weeks - expect additional 1.5-2.5 mmHg reduction
4. Monitor for conjunctival hyperemia at each visit
5. If hyperemia is problematic but IOP control is good, counsel patient that it typically resolves with continued use or upon discontinuation

The guideline explicitly states: "If a drug fails to reduce IOP sufficiently, then either switching to an alternative medication as monotherapy or adding additional medication is appropriate until the desired IOP level is attained" 1.