What is a prescription-grade alternative to Restasis (cyclosporine) for a patient with dry eyes?

Prescription-Grade Alternatives to Restasis for Dry Eye Disease

Lifitegrast 5% ophthalmic solution (Xiidra) is the most effective prescription-grade alternative to Restasis (cyclosporine) for patients with dry eye disease. 1

First-Line Prescription Alternatives

Lifitegrast (Xiidra)

• FDA-approved specifically for dry eye disease
• Mechanism: Lymphocyte function-associated antigen-1 (LFA-1) antagonist
• Benefits: Improves both signs (corneal and conjunctival staining) and symptoms (eye dryness and ocular discomfort) 2
• Onset: Shows benefits over a 3-month period, faster than cyclosporine products 2
• Dosing: Twice daily administration
• Limitation: Long-term efficacy beyond 12 months is not well established 2

Other Cyclosporine Formulations

• VEVYE® (cyclosporine 0.1% ophthalmic solution)
• CEQUA™ (cyclosporine 0.09% ophthalmic solution) 3
• These newer formulations may provide better tolerability than Restasis for some patients

Second-Line Prescription Options

Corticosteroid Options

• EYSUVIS™ (loteprednol etabonate ophthalmic suspension 0.25%)
• Indicated for short-term use (2-4 weeks) for acute inflammatory signs 1
• Caution: Requires monitoring for increased intraocular pressure and infection risk

Novel Agents

• MIEBO™ (perfluorohexyloctane ophthalmic solution) - a semifluorinated alkane 3
• TYRVAYA™ (varenicline solution nasal spray) - a cholinergic agonist that increases tear production 3

For Severe Dry Eye Refractory to Standard Treatments

Autologous Serum Eye Drops

• Highly effective and safe alternative for severe cases 2
• Contains factors that promote ocular surface renewal and restore tear film homeostasis 1
• Particularly useful when other treatments have failed

Oral Medications

• For patients with Sjögren's syndrome (combined dry eye and dry mouth):
  • Cevimeline: FDA-approved for symptoms of dry mouth in Sjögren's syndrome
  • Has been shown to improve ocular irritation symptoms and aqueous tear production
  • May have fewer adverse systemic side effects than oral pilocarpine 2

Treatment Selection Algorithm

1. Assess severity and mechanism of dry eye:

   • Mild to moderate: Consider Xiidra as first alternative to Restasis
   • Moderate to severe with inflammation: Consider newer cyclosporine formulations or short-term steroids
   • Severe refractory cases: Consider autologous serum eye drops

2. Consider patient-specific factors:

   • History of burning/stinging with Restasis: Try Xiidra or newer cyclosporine formulations
   • Need for faster onset: Xiidra may provide quicker relief than cyclosporine products
   • Presence of Sjögren's syndrome: Consider adding oral medications

Important Clinical Considerations

• Burning sensation is a common side effect with cyclosporine products; lifitegrast may cause dysgeusia (taste disturbance) 4
• Patient education is crucial for treatment success - many patients discontinue treatment prematurely due to side effects or perceived lack of efficacy 5
• Combination therapy may be more effective than monotherapy for moderate to severe cases
• Temporary punctal plugs (silicone or collagen) can be used as a trial before permanent occlusion 1
• Regular follow-up is necessary to monitor response and adjust treatment as needed

Advanced Options for Severe Cases

• Rigid gas-permeable scleral lenses have been used successfully in severe dry eye but may be limited by fitting difficulties and cost 2
• Amniotic membrane grafts can be considered for refractory cases, though effects may be short-term 2

Physicians report that while current treatments are helpful, there remains a significant need for additional treatment options for dry eye disease, with more than 50% strongly agreeing that more options are needed 4.