What medications should be avoided or used with caution in patients with glaucoma?

From the Guidelines

Patients with glaucoma should avoid or use with caution several medication classes that can increase intraocular pressure or worsen the condition, including anticholinergics, corticosteroids, sympathomimetics, certain antidepressants, and mydriatic agents, as they can block drainage of aqueous humor, raise eye pressure, or dilate pupils and potentially block drainage angles. When considering medications to avoid or use with caution in patients with glaucoma, it is essential to prioritize those that can increase intraocular pressure or worsen the condition.

• Anticholinergics, including some antihistamines (diphenhydramine) and overactive bladder medications (oxybutynin), should be avoided, particularly in narrow-angle glaucoma, as they can block drainage of aqueous humor 1.
• Corticosteroids (prednisone, dexamethasone, fluticasone) in any form—oral, inhaled, topical, or injected—can significantly raise eye pressure and should be used cautiously with regular monitoring.
• Sympathomimetics found in decongestants and cold medicines (pseudoephedrine, phenylephrine) can worsen glaucoma by dilating pupils and potentially blocking drainage angles.
• Some antidepressants, particularly SSRIs and SNRIs (fluoxetine, venlafaxine), may rarely affect pupil size and should be monitored.
• Certain anti-seizure medications like topiramate can paradoxically cause acute angle closure.
• Mydriatic agents that dilate pupils (atropine, tropicamide) are particularly dangerous in narrow-angle glaucoma. According to the most recent study 1, prostaglandin analogs are the most frequently prescribed eye drops for lowering IOP because they are the most efficacious and well-tolerated glaucoma medication, and they need to be instilled only once daily. Patients should always inform healthcare providers about their glaucoma diagnosis before starting new medications, and those with narrow-angle glaucoma generally need more careful medication selection than those with open-angle glaucoma.

From the FDA Drug Label

Steroids should be used with caution in the presence of glaucoma. Prolonged use of corticosteroids may result in glaucoma with damage to the optic nerve, defects in visual acuity and fields of vision, and in posterior subcapsular cataract formation.

Medications to avoid or use with caution in patients with glaucoma include:

• Corticosteroids, such as prednisolone acetate 2 and loteprednol 3, which should be used with caution in the presence of glaucoma due to the risk of increased intraocular pressure (IOP) and potential damage to the optic nerve.
• Key considerations for patients with glaucoma:
  • IOP should be checked frequently when using corticosteroids
  • Use of corticosteroids may mask or enhance existing infections, and may prolong the course and exacerbate the severity of viral infections of the eye.

From the Research

Medications to Avoid with Glaucoma

Medications that can exacerbate glaucoma or increase intraocular pressure (IOP) should be used with caution or avoided in patients with glaucoma. These include:

• Corticosteroids, which can increase IOP and worsen glaucoma 4, 5
• Anticholinergics, which can increase IOP and exacerbate glaucoma 4
• Certain antidepressants, which can increase IOP and worsen glaucoma 4
• Topiramate, which can increase IOP and worsen glaucoma 4

Systemic Medical Conditions and Medications

Several systemic medical conditions and medications can increase the risk of glaucoma, including:

• Systemic corticosteroid use, which can increase IOP and worsen glaucoma 5
• Certain antidepressants, which can increase IOP and worsen glaucoma 4
• Anticholinergics, which can increase IOP and exacerbate glaucoma 4

Glaucoma Treatment and Medications

Glaucoma treatment typically involves lowering IOP to prevent further progression of the disease. Medications used to treat glaucoma include:

• Topical beta-blockers, which can lower IOP but may have systemic side effects 6
• Prostaglandin analogs, which can lower IOP and are often used as first-line treatment 6
• Alpha-2 agonists and parasympathomimetics, which can lower IOP and are often used as second- or third-line treatment 6
• Carbonic anhydrase inhibitors (CAIs), which can lower IOP and are often used in acute settings or for patients resistant to other glaucoma medications 6

Side Effects of Glaucoma Medications

Glaucoma medications can have ocular and systemic side effects, including:

• Ocular surface changes induced by long-term antiglaucomatous treatment, especially by preservatives 7
• Systemic effects and potential interactions with other drugs due to absorption into conjunctival and nasal mucosas 7