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 antipsychotics, and some anti-seizure medications.

Medications to Avoid

The following medications can exacerbate glaucoma:

• Anticholinergics, such as diphenhydramine, oxybutynin, and amitriptyline, which can cause pupillary dilation and potentially trigger acute angle-closure glaucoma 1
• Corticosteroids, including prednisone, dexamethasone, and fluticasone, in any form, which can increase intraocular pressure, particularly with prolonged use 1
• Sympathomimetics found in decongestants and cold medications, such as pseudoephedrine and phenylephrine, which can worsen glaucoma by dilating the pupil 1
• Certain antipsychotics with strong anticholinergic effects, such as chlorpromazine, and some anti-seizure medications, such as topiramate, which also pose risks 1

Considerations for Patients with Glaucoma

Patients with narrow-angle glaucoma face greater risks with these medications than those with open-angle glaucoma. It is essential to inform all healthcare providers about the glaucoma diagnosis, and if these medications must be used, more frequent monitoring of intraocular pressure may be necessary. Alternative medications with less impact on glaucoma are often available and should be discussed with the healthcare provider. The most recent study 1 suggests that prostaglandin analogs are the most frequently prescribed eye drops for lowering IOP and are often considered as initial medical therapy unless other considerations preclude this. Topical beta adrenergic antagonists, such as timolol, are also commonly prescribed to treat glaucoma and have demonstrated good efficacy and tolerability. However, nighttime dosing of beta-blockers is associated with limited efficacy and may contribute to visual field progression via nocturnal reduction of systemic blood pressure. Other glaucoma medications, including alpha 2 adrenergic agonists, topical and oral carbonic anhydrase inhibitors, rho kinase inhibitors, and parasympathomimetics, may also be considered. Ultimately, the choice of medication should be individualized based on the patient's specific needs and medical history.

From the FDA Drug Label

WARNINGS: FOR TOPICAL OPHTHALMIC USE. 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. Steroids should be used with caution in the presence of glaucoma. WARNINGS 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. Steroids should be used with caution in the presence of glaucoma.

Medications to Avoid or Use with Caution in Patients with Glaucoma:

• Corticosteroids: should be used with caution in patients with glaucoma, as prolonged use may result in glaucoma with damage to the optic nerve, defects in visual acuity and fields of vision, and in posterior subcapsular cataract formation 2, 3. Key Considerations:
• Intraocular pressure (IOP) should be routinely monitored when using corticosteroids for 10 days or longer 2.
• IOP should be checked frequently when using steroids in the presence of glaucoma 2, 3.

From the Research

Medications to Avoid with Glaucoma

Medications that can exacerbate or induce glaucoma include:

• Corticosteroids, which can increase the risk of glaucoma by raising the intraocular pressure (IOP) 4
• Adrenergic agonists, cholinergics, anticholinergics, sulpha-based drugs, selective serotonin reuptake inhibitors, tricyclic and tetracyclic antidepressants, anticoagulants, and histamine H(1) and H(2) receptor antagonists, which can induce or precipitate acute angle-closure glaucoma 5
• Topiramate, which has been associated with acquired myopia and angle-closure glaucoma 6
• Tricyclic antidepressants (TCAs), typical antipsychotics, and selective serotonin reuptake inhibitors (SSRIs), which can cause mydriasis and promote closure of angles in susceptible patients 5, 6

Precautions and Considerations

When using medications that can affect glaucoma, it is essential to:

• Use corticosteroids judiciously and with caution, especially in patients with a family history of glaucoma 4, 7
• Monitor intraocular pressure regularly in patients using medications that can affect glaucoma 4, 5
• Be aware of the potential for medication-induced glaucoma and take preventive measures to minimize the risk 5, 6
• Consider alternative medications or treatment options for patients with glaucoma or those at risk of developing glaucoma 8, 6