From the Guidelines
Patients with glaucoma can use steroid inhalers like Fluticasone propionate, but should do so with caution and regular monitoring, as inhaled corticosteroids can potentially increase intraocular pressure 1.
Key Considerations
- These patients should inform their ophthalmologist about their inhaler use and maintain regular eye pressure checks.
- When prescribed, patients should use the lowest effective dose of Fluticasone propionate (typically starting at 100-250 mcg twice daily) and follow proper inhaler technique, including rinsing the mouth after use to minimize systemic absorption.
- Alternative controller medications like leukotriene modifiers or long-acting beta-agonists might be considered in patients with severe or poorly controlled glaucoma.
Rationale
The concern with steroid inhalers stems from their potential to elevate intraocular pressure, particularly with higher doses or prolonged use, though the risk is significantly lower than with oral or ocular steroids 1.
Monitoring and Treatment
Most patients with stable glaucoma can safely use inhaled corticosteroids when benefits outweigh risks, but individualized treatment decisions should be made based on the severity of both respiratory disease and glaucoma 1.
Additional Guidance
It is essential to educate patients about the potential risks and benefits of inhaled corticosteroids and the importance of regular monitoring, as well as to consider comorbidities and other factors that may influence treatment decisions 1.
From the FDA Drug Label
5.15 Glaucoma and Cataracts Glaucoma, increased intraocular pressure, and cataracts have been reported in patients with asthma and COPD following the long-term administration of ICS, including fluticasone propionate, a component of Wixela Inhub® Consider referral to an ophthalmologist in patients who develop ocular symptoms or use Wixela Inhub® long term. The incidence of newly diagnosed glaucoma was 2% with fluticasone propionate and salmeterol inhalation powder 500 mcg/50 mcg, 5% with fluticasone propionate, 0% with salmeterol, and 2% with placebo.
Recommendations for using a steroid inhaler in patients with glaucoma:
- Consider referral to an ophthalmologist in patients who develop ocular symptoms or use the steroid inhaler long term.
- Patients with glaucoma should be closely monitored for increased intraocular pressure.
- The use of steroid inhalers, including fluticasone propionate, may increase the risk of glaucoma, with an incidence of newly diagnosed glaucoma reported in clinical trials 2.
- Key considerations:
- Monitor patients with glaucoma for worsening of the condition.
- Weigh the benefits and risks of using a steroid inhaler in patients with glaucoma.
- Consider alternative treatments if possible.
From the Research
Recommendations for Using Steroid Inhalers in Patients with Glaucoma
The use of steroid inhalers, such as Fluticasone propionate, in patients with glaucoma has been studied in several research papers. Here are the key findings:
- A study published in 2017 3 found no clinically significant increase in mean intraocular pressure (IOP) in patients with well-controlled open-angle glaucoma and ocular hypertension after 6 weeks of twice-daily inhaled fluticasone propionate compared with inhaled placebo.
- Another study published in 2012 4 found that inhaled fluticasone at the regular dose used in the study over a short period (6-24 months) was not associated with a significant effect on central corneal thickness (CCT) and IOP measured with noncontact devices in asthmatic children between 5 and 15 years, without a family history of glaucoma.
- A study published in 1996 5 found no significant rise in IOP in patients receiving inhaled steroid therapy, with no patient having a rise in IOP greater than 4 mm Hg.
- However, it's worth noting that these studies focused on the use of steroid inhalers in patients without pre-existing glaucoma or with well-controlled glaucoma, and the results may not be generalizable to all patients with glaucoma.
Key Findings
Some key findings from the studies include:
- No significant difference in IOP between patients using steroid inhalers and those using placebo 3, 5
- No significant effect on CCT and IOP in asthmatic children without a family history of glaucoma 4
- No increase in IOP and no increase in antihypertensive drops in patients with pre-existing glaucoma drainage devices 6
- A meta-analysis of 18 studies found no significant difference in crude glaucoma incidence, adjusted glaucoma incidence, crude prevalence, adjusted prevalence, IOP change during ICS treatment, and single measurement IOP between patients using steroid inhalers and those not using them 7
Considerations for Patients with Glaucoma
Patients with glaucoma should consult their doctor before using steroid inhalers, as the risks and benefits of treatment need to be carefully weighed. Regular monitoring of IOP and adjustment of treatment as needed is crucial to minimize the risk of glaucoma progression.