Is the Trelegy (fluticasone furoate, umeclidinium, vilanterol) inhaler safe for a patient with glaucoma?

Trelegy Inhaler Safety in Glaucoma Patients

Trelegy (fluticasone furoate/umeclidinium/vilanterol) can be used cautiously in patients with glaucoma, but requires specific precautions due to the anticholinergic component (umeclidinium) and the inhaled corticosteroid (fluticasone furoate), both of which carry glaucoma-related risks. 1

Primary Safety Concerns

Anticholinergic Risk (Umeclidinium)

The umeclidinium component poses the most immediate concern for glaucoma patients:

• Anticholinergics can precipitate acute angle-closure glaucoma, particularly in patients with narrow anterior chamber angles 2, 3
• The risk is highest when anticholinergics reach the eyes directly, causing pupillary dilation and potential angle closure 4
• In patients with narrow-angle glaucoma, combined anticholinergic therapy has been shown to cause transient angle closure and elevated intraocular pressure 3

Inhaled Corticosteroid Risk (Fluticasone Furoate)

The FDA label explicitly warns that glaucoma and cataracts may occur with long-term use of inhaled corticosteroids 1:

• Glaucoma, increased intraocular pressure, and cataracts have been reported following long-term ICS administration 1
• In patients with a family history of glaucoma, inhaled corticosteroids show a strong association with elevated IOP or glaucoma (odds ratio 2.6), with risk increasing at higher doses 5
• However, a randomized controlled trial found no clinically significant IOP increase in patients with well-controlled open-angle glaucoma after 6 weeks of inhaled fluticasone propionate 6

Type of Glaucoma Matters

Open-Angle Glaucoma

• Trelegy can generally be used with appropriate monitoring in open-angle glaucoma patients 3
• Nebulized bronchodilator therapy (including anticholinergics) is safe in patients with open-angle glaucoma, with no significant IOP rise 3
• Beta-agonists like vilanterol do not affect intraocular pressure or pupillary dilation 4

Narrow-Angle or Angle-Closure Glaucoma

• Exercise extreme caution or consider alternatives in narrow-angle glaucoma 3
• Anticholinergics can cause acute angle closure in these patients, particularly when combined with other bronchodilators 3
• The dim lighting conditions that cause mydriasis can increase risk of pupillary block leading to acute angle-closure 2

Essential Monitoring and Precautions

All glaucoma patients using Trelegy require:

• Referral to an ophthalmologist for patients who develop ocular symptoms or use Trelegy long-term 1
• Regular ophthalmologic supervision with intraocular pressure monitoring 4
• Immediate evaluation if symptoms of angle-closure develop (eye pain, blurred vision, halos around lights) 7

Critical Pitfalls to Avoid

• Never assume all inhaler components are equally safe - the anticholinergic specifically carries glaucoma risk while the beta-agonist does not 4
• Do not overlook family history of glaucoma, as this significantly increases risk with inhaled corticosteroids 5
• Ensure patients understand to report any new ocular symptoms immediately 7

Clinical Decision Algorithm

1. Determine glaucoma type: Open-angle versus narrow-angle/angle-closure
2. If open-angle glaucoma: Trelegy can be used with ophthalmologic monitoring 3
3. If narrow-angle or angle-closure glaucoma: Consider alternative therapies without anticholinergics, or use with extreme caution and close ophthalmologic supervision 3
4. Assess family history: Patients with glaucoma family history require heightened monitoring due to increased ICS-related risk 5
5. Establish monitoring plan: Arrange regular ophthalmologic follow-up before initiating therapy 4, 1