First-Line Treatment for Ocular Hypertension in Patients on ESA
Prostaglandin analogs (PGAs) are the recommended first-line medical therapy for ocular hypertension in patients on erythropoiesis-stimulating agents, with no specific contraindication to their use in this population. 1
Primary Treatment Recommendation
Prostaglandin analogs should be initiated as first-line therapy because they are the most efficacious class of IOP-lowering medications, are well-tolerated, require only once-daily dosing, and have minimal systemic side effects—a critical consideration for patients already on ESA therapy who may have cardiovascular comorbidities. 1
The most effective PGAs in order of IOP reduction at 3 months are: bimatoprost (5.61 mmHg reduction), latanoprost (4.85 mmHg), and travoprost (4.83 mmHg), though the clinical differences between these agents are small and may not be clinically meaningful. 2
Latanoprost 0.005% once daily is often selected as initial therapy due to its established efficacy (22-39% IOP reduction), extensive safety data, and cost-effectiveness compared to other PGAs. 3, 4
ESA-Specific Considerations
There is no contraindication to using prostaglandin analogs in patients on ESA therapy. The KDOQI guidelines for anemia management in chronic kidney disease (the primary indication for ESA use) do not restrict the use of topical glaucoma medications. 1
Hypertension, which may develop or worsen with ESA therapy, is not a contraindication to IOP-lowering treatment. If hypertension arises during glaucoma treatment, it should be managed with appropriate antihypertensive measures rather than withholding glaucoma therapy. 1
Beta-blockers (such as timolol) should be used with caution in ESA patients who may have cardiovascular disease, as systemic absorption can cause cardiopulmonary adverse effects. This further supports PGAs as the preferred first-line choice. 1, 3
Treatment Algorithm
Initiate latanoprost 0.005% one drop once daily in the affected eye(s) as first-line therapy. 3
If latanoprost is insufficient or not tolerated, switch to bimatoprost 0.03% or travoprost 0.004% once daily, which may provide slightly greater IOP reduction. 2, 4
If monotherapy fails to achieve target IOP (typically 25% reduction from baseline), add a second agent from a different class rather than switching, with beta-blockers (timolol 0.25-0.5% twice daily) being the most common adjunctive therapy—though monitor carefully for systemic effects in ESA patients. 1, 5
Consider selective laser trabeculoplasty as an alternative to medications, particularly if medication adherence is a concern or if the patient experiences intolerable side effects from topical therapy. 1
Monitoring Requirements
Measure IOP after approximately 4 weeks of initiating PGA therapy to assess response, as the pressure-lowering effect may require several weeks to stabilize. 5
Follow patients with ocular hypertension every 12-24 months if untreated and being observed, or more frequently (every 3-6 months) if on treatment until IOP control is achieved. 1
Monitor for cardiovascular complications in ESA patients, as these patients may have pre-existing cardiovascular disease that requires closer surveillance during any IOP-lowering therapy. 1
Common Pitfalls to Avoid
Do not avoid PGA therapy due to concerns about systemic effects in ESA patients—PGAs have near absence of systemic side effects compared to beta-blockers or oral carbonic anhydrase inhibitors. 4, 6
Do not use oral carbonic anhydrase inhibitors (acetazolamide) as first-line therapy in ESA patients, as these have significant systemic side effects including electrolyte disturbances that could complicate management of chronic kidney disease patients on ESA. 7, 8
Counsel patients about expected ocular side effects of PGAs including conjunctival hyperemia (3-15%), iris pigmentation changes (2-9%), and periocular skin darkening, which are generally mild but may affect adherence if unexpected. 3, 4