Management of PPIs in Patients with Glaucoma
Continue PPIs in glaucoma patients without modification, as there is no established contraindication or clinically significant interaction between proton pump inhibitors and glaucoma or its treatments. The primary glaucoma management guidelines do not identify PPIs as a risk factor or contraindication for glaucoma therapy 1.
Key Management Principles
Standard Glaucoma Care Remains Unchanged
- Prostaglandin analogs remain first-line therapy for IOP reduction in glaucoma patients taking PPIs, offering 20-35% IOP reduction with once-daily dosing and minimal systemic effects 2
- Monitor IOP, optic nerve structure, and visual fields regularly regardless of PPI use 1
- Target IOP reduction of at least 20-30% from baseline 2, 3
PPI Selection Considerations
When PPIs are medically necessary in glaucoma patients on antiplatelet therapy (a scenario where PPIs are specifically recommended):
- Prefer pantoprazole or dexlansoprazole over omeprazole or esomeprazole if the patient is taking clopidogrel, as these do not interfere with cytochrome P450 2C19 activity 1
- This recommendation stems from cardiovascular guidelines addressing drug-drug interactions with antiplatelet agents, not glaucoma-specific concerns 1
No Direct PPI-Glaucoma Interaction
The comprehensive glaucoma management guidelines make no mention of PPIs as:
- A risk factor for glaucoma development 1
- A contraindication to glaucoma medications 1
- A factor requiring treatment modification 1
Clinical Approach
Continue Current Medications
- Do not discontinue or modify PPIs based solely on glaucoma diagnosis 1
- PPIs have minimal systemic effects and no documented impact on intraocular pressure 4, 5
- All PPIs (omeprazole, lansoprazole, pantoprazole, rabeprazole, esomeprazole) are metabolized hepatically with minimal risk of clinically significant interactions with glaucoma medications 4
Focus on Glaucoma Treatment Optimization
- Ensure adherence to glaucoma medications through patient education and simplified regimens 1
- Address medication side effects and systemic contraindications specific to glaucoma drugs (e.g., beta-blockers in asthma/COPD) 2
- Consider fixed-combination therapy if multiple glaucoma medications are needed to improve adherence 1
Common Pitfalls to Avoid
- Do not assume PPIs worsen glaucoma - there is no evidence supporting this concern in major ophthalmology guidelines 1
- Do not discontinue medically necessary PPIs for unfounded concerns about glaucoma progression 1
- Do not confuse PPI-clopidogrel interactions (relevant in cardiovascular disease) with glaucoma management 1