What are prescription alternatives to Xiidra (lifitegrast) for a patient with dry eye syndrome?

Prescription Alternatives to Xiidra for Dry Eye Disease

Cyclosporine 0.05% ophthalmic solution (Restasis) is the primary prescription alternative to Xiidra for dry eye disease, with demonstrated efficacy in 74% of mild, 72% of moderate, and 67% of severe dry eye cases. 1

Second-Line Prescription Options

Cyclosporine 0.05% (Restasis) - First Alternative

• Cyclosporine 0.05% works by preventing T-cell activation and inflammatory cytokine production while inhibiting mitochondrial pathways of apoptosis 1, 2
• Dosing is one drop in each eye twice daily, approximately 12 hours apart 3, 2
• FDA approval was based on trials showing a statistically significant 10-mm increase in Schirmer test results at 6 months in 15% of cyclosporine-treated patients versus 5% of vehicle-treated patients 1
• After 1 full year of twice-daily therapy, the dose can be decreased to once daily in select patients without loss of beneficial effects 1
• The most common adverse effect is ocular burning in approximately 17% of patients, but this is generally well tolerated 1

Varenicline Nasal Spray (Tyrvaya) - Alternative Mechanism

• Tyrvaya is a highly selective nicotinic acetylcholine receptor agonist administered as a nasal spray that works as a neuroactivator of tear film production 1
• It activates nicotinic acetylcholine receptors on the trigeminal nerve within the nasal mucosa, stimulating the lacrimal functional unit to produce natural tears 1
• This represents a fundamentally different mechanism than traditional eye drops, which either supplement the tear film or reduce ocular surface inflammation 1
• Tyrvaya can be considered for patients who have inadequate response to or intolerance of traditional eye drops 1

Short-Term Topical Corticosteroids - Adjunctive Therapy

• Topical corticosteroids can decrease ocular irritation symptoms and corneal fluorescein staining 1, 3
• Use should be strictly limited to 2-4 weeks maximum to avoid complications including infections, increased intraocular pressure, and cataract development 1, 3, 2

Treatment Algorithm Based on Disease Severity

For Moderate Dry Eye (When Artificial Tears Are Insufficient)

• Add cyclosporine 0.05% as the standard second-line treatment 1, 2
• Consider short-term topical corticosteroids (2-4 weeks) for acute exacerbations 1, 3

For Moderate to Severe Dry Eye with Inadequate Response

• Consider varenicline nasal spray (Tyrvaya) for patients who fail traditional eye drops 1
• Evaluate for advanced treatments including punctal occlusion, autologous serum eye drops, or oral secretagogues 1, 3

Advanced Treatment Options for Severe Cases

Mechanical Interventions

• Punctal plugs using temporary silicone plugs or permanent thermal/laser cautery for tear retention after optimizing topical therapy 1, 3

Autologous Serum Eye Drops

• Beneficial for severe dry eye, particularly in Sjögren's syndrome 1, 3
• Improve ocular irritation symptoms and corneal/conjunctival staining 1, 2

Oral Secretagogues

• Pilocarpine 5 mg orally four times daily or cevimeline can stimulate tear production in patients with Sjögren's syndrome 4, 1, 3
• Most common side effect is excessive sweating, occurring in over 40% of patients 4

Critical Pitfalls to Avoid

• Failing to recognize when to advance therapy from artificial tears to anti-inflammatory agents in moderate to severe disease leads to inadequate treatment 1
• Extended use of topical corticosteroids beyond 4 weeks risks serious complications 1, 2
• Neglecting underlying blepharitis or meibomian gland dysfunction can exacerbate dry eye and must be treated concurrently 1, 2

When to Refer to Ophthalmology

• Moderate or severe eye pain unresponsive to initial therapy 2
• Lack of response after 2-4 weeks of optimized treatment 2
• Corneal infiltration, ulceration, or any vision loss 4, 2
• Progressive conjunctival scarring 4