Is Breztri (budesonide, glycopyrrolate, formoterol) safe to use in patients with open angle glaucoma?

Safety of Breztri in Patients with Open Angle Glaucoma

Breztri (budesonide, glycopyrrolate, formoterol) should be used with caution in patients with open-angle glaucoma, with close monitoring of intraocular pressure and vision changes due to the potential risk of worsening glaucoma from the corticosteroid component.

Understanding the Components and Concerns

Breztri is a triple combination inhaler containing:

1. Budesonide - An inhaled corticosteroid
2. Glycopyrrolate - An anticholinergic bronchodilator
3. Formoterol - A long-acting beta-agonist

Corticosteroid Component (Budesonide) and Glaucoma

• Inhaled corticosteroids like budesonide can cause glaucoma, increased intraocular pressure (IOP), and cataracts with long-term administration 1
• Close monitoring is warranted in patients with a history of increased IOP, glaucoma, and/or cataracts 1
• Corticosteroid use is a major risk factor in the development and aggravation of glaucoma due to augmentation of IOP 2
• The FDA label for budesonide specifically lists glaucoma as an adverse reaction that has been reported during post-approval use 1

Risk Assessment

Risk Factors for Steroid-Induced IOP Elevation

• Personal or family history of primary open-angle glaucoma is the most important risk factor for steroid responsiveness 2
• The risk depends on:
  • Type of preparation
  • Mode of administration
  • Dosage
  • Duration of therapy 2

Monitoring and Management Recommendations

• IOP monitoring: Regular follow-up of IOP after initiating Breztri therapy 2
• Vision assessment: Monitor for changes in vision 1
• Ophthalmologic evaluation: Consider baseline and periodic eye examinations 1

Clinical Decision Algorithm

1. Assess baseline risk:

   • Determine severity of existing open-angle glaucoma
   • Check current IOP control
   • Review other risk factors 3

2. Consider alternative treatments if glaucoma is severe or poorly controlled:

   • Other classes of respiratory medications with lower risk of affecting IOP 3

3. If Breztri is necessary (when benefits outweigh risks):

   • Establish baseline IOP measurement
   • Ensure patient has appropriate glaucoma therapy in place
   • Schedule more frequent ophthalmologic follow-ups 1

4. Monitor for warning signs:

   • Changes in vision
   • Eye pain
   • Headaches
   • Worsening of visual field defects 3

Comparative Medication Considerations

When considering alternatives for patients with open-angle glaucoma:

• Anticholinergics (like glycopyrrolate in Breztri) should be used with caution in patients with narrow-angle glaucoma, but are generally considered safer in open-angle glaucoma 3
• Beta-blockers used for glaucoma treatment may have interactions with beta-agonists (like formoterol in Breztri) 3
• Phentermine/topiramate is specifically contraindicated in untreated closed-angle glaucoma, but not in open-angle glaucoma 3

Conclusion

While Breztri is not absolutely contraindicated in patients with open-angle glaucoma, the corticosteroid component (budesonide) requires careful consideration and monitoring. The risk of worsening glaucoma must be weighed against the respiratory benefits of the medication. Regular ophthalmologic evaluations and IOP monitoring are essential for patients with open-angle glaucoma who require Breztri therapy.