Can chlordiazepoxide and clidinium be used in patients with glaucoma?

Chlordiazepoxide and Clidinium Use in Glaucoma

Chlordiazepoxide and clidinium combination is contraindicated in patients with glaucoma due to the anticholinergic effects of clidinium, which can cause mydriasis and potentially precipitate an angle-closure attack. 1

Mechanism of Risk

• Clidinium, an anticholinergic agent in this combination medication, can cause pupillary dilation (mydriasis) which may precipitate angle-closure in predisposed patients 1, 2
• Anticholinergic drugs can induce or exacerbate angle-closure glaucoma, particularly in individuals with anatomically narrow angles 2
• The FDA drug label explicitly lists glaucoma as a contraindication for chlordiazepoxide and clidinium combination therapy 1

Types of Glaucoma and Risk Assessment

• There are two main types of glaucoma that must be distinguished when considering anticholinergic medications 3:

  • Open-angle glaucoma: More common, characterized by normal angle anatomy but impaired aqueous outflow
  • Angle-closure glaucoma: Less common, characterized by narrowed iridocorneal angles that can become blocked

• The risk is particularly high for patients with:

  • Anatomically narrow anterior chamber angles 4
  • History of intermittent angle closure symptoms (blurred vision, halos around lights, eye pain) 4
  • Hyperopia (far-sightedness), especially in older phakic patients 4

Benzodiazepine Component Considerations

• Chlordiazepoxide (the benzodiazepine component) may independently increase risk of acute angle-closure glaucoma 5
• A population-based case-crossover study found benzodiazepine use was associated with a 40% increased risk of acute angle-closure glaucoma (adjusted OR = 1.40; 95% CI 1.27-1.54) 5

Alternative Approaches

• For patients requiring treatment for irritable bowel syndrome or peptic ulcers who also have glaucoma, alternative medications without anticholinergic properties should be considered 1
• If anticholinergic therapy is absolutely necessary for a patient with open-angle glaucoma:
  • Consultation with an ophthalmologist is mandatory before initiating therapy 3
  • Some studies suggest that certain anticholinergics may be used in treated open-angle glaucoma with careful monitoring 6, 3
  • However, the specific combination of chlordiazepoxide and clidinium remains contraindicated due to its explicit FDA warning 1

Clinical Recommendations

• Screen all patients for glaucoma history before prescribing chlordiazepoxide and clidinium 3
• For patients with known glaucoma, avoid this medication combination entirely 1
• For patients with risk factors for angle closure but no diagnosis, ophthalmologic evaluation should precede any consideration of anticholinergic therapy 7
• Monitor for signs of angle-closure glaucoma in all patients taking medications with anticholinergic effects, including eye pain, blurred vision, and halos around lights 7, 4

Conclusion

The anticholinergic properties of clidinium make the chlordiazepoxide-clidinium combination unsafe for use in patients with glaucoma, particularly those with angle-closure glaucoma or anatomically narrow angles. The FDA drug label explicitly contraindicates this medication in glaucoma patients, and this warning should be strictly followed to prevent potentially serious visual complications.