Dr. Casella reviews vitamin B3 for glaucoma management

October 30, 2020
Brooke Beery, Associate Editor
Brooke Beery, Associate Editor

Brooke Beery is Assistant Editor of Optometry Times®.

,
Benjamin P. Casella, OD, FAAO

A world-first clinical trial led by the Centre for Eye Research Australia shows vitamin B3 (nicotinamide) could play an important role in protecting against nerve cell damage that leads to blindness in glaucoma patients.

Brooke Beery: I am Brooke Berry, assistant editor of Optometry Times® magazine, and I have the pleasure of being joined today by Chief Optometric Editor, Dr. Ben Casella, who practices in Augusta, Georgia. Hi, Dr. Casella. It’s such a pleasure to have you here.

Ben Casella, OD, FAAO: How are you, my friend?

Beery: I am doing well. Thank you for joining us.

Casella: You are very welcome.

Beery: So, how are things in Georgia? Is it starting to feel like fall yet there, are your leaves still green?

Casella: Our leaves are still green. We got lost a couple of weekends ago. We took the kids up to Pigeon Forge, did some hiking, got pretty close to the Appalachian Trail. Some of the leaves are starting to turn, but down in Augusta it is going to be about another month, month and a half, before it gets golden. But yeah, the nights are getting a little cooler—the high today was like 70˚. So, everybody had jackets on. That is going to make a lot of people laugh, but that is cold to us, especially end of September. We were feeling good and staying safe. Just keeping the pedal to the metal.

Beery: That is all you can ask for, really. Here in Ohio, there is a definite chill in the air. But we are kind of used to it. I guess, I would say it is beginning our 8-month dive into sweater season, and we are used to it.

Casella: As one does, yeah.

Related: Glaucoma & ocular surface preservation: Key factors for ODs to consider

Beery: But I would like to talk about one of your strongest areas of interest, and that is glaucoma. You are our glaucoma guy. And so when we found this research study, it is new and exciting, I knew I had to talk to you about it. It is a clinical trial, led by Melbourne researchers suggesting vitamin B3 could play an important role in glaucoma management. Results of this trial showed significant improvement in the visual function of glaucoma patients who received a daily high dose of vitamin B3 for 12 weeks. This sounds pretty exciting. What does this news mean for ODs and for glaucoma patients? Is B3 a solid treatment option for glaucoma?

Casella: Not right now. At current time, we still don't have any therapy for glaucoma which should come before lowering IOP. The drops, surgical and laser procedures that we have for lowering intraocular pressure are still first-line therapy, and they are going to be first-line therapy for a while. But this study describes, in my opinion, a solid effort which certainly needs further research to investigate the concept of neuroprotection, something that we can do beyond lowering IOP to protect these neurons that just die off at such a quick rate in the presence of glaucoma.

Another thing that this study hints at is in glaucoma, we work so hard just to keep things from getting worse. This study shows some improvement in visual function with respect to glaucoma. It was a small study. Some 50 patients fit the criteria for the study, 40-something patients completed the study. So, that is quite small. The follow-up period of 12 weeks is quite small.

But it certainly points to the fact that we need, and the authors say this in their discussion, that we need longer studies and studies that have greater cohorts to see if B3 is really onto something here. There is a piece in Journal of Glaucoma, that goes back to 2017, that purports that supplementation with vitamin B3 may lead to a 10-fold decrease in your risk of developing glaucoma. So, vitamin B3 has been chatted about in the field of glaucoma for several years now. And this is a very intriguing study. I am certainly on the lookout for more and larger cohorts over longer periods of time to see if this is something that pans out. Because vitamin B3 is relatively inexpensive. Not to be pragmatic.

Related: Optimizing ocular blood flow in glaucoma management

Beery: It is inexpensive, so do you think glaucoma patients who have seen the study or read about it online should go out and look for B3? Or are you saying hold off on that and not jump into B3 right away?

Casella: We need more research, for sure. Now that said if your IOP is really low, like if it is 8 or 9 mm Hg, or if it is approaching episcleral venous pressure—If is really not going to get any lower and you are continuing to progress, maybe go get you some B3, go get you some gingko. But no, there is no reason to change current protocol at this point.

Beery: OK. Good to know. And for fellow ODs: Do you think they should keep their eyes on B3 or maybe prescribe it?

Casella: Yeah, that is a really good question for fellow ODs. They should go to PubMed.gov once every month or so, type in the word “glaucoma,” and see what the peer-reviewed research says. You should not rely solely on conferences, or solely on the publications to which you prescribe. You should be actively going out and looking at peer-reviewed research on a monthly basis, especially if you do a lot of glaucoma management. Or just insert "disease X” into the search box on PubMed.com. But, we certainly have to stay abreast. We have a fiduciary obligation to tell patients what is good and what is not good. But there is no reason to change current protocol, yet. I will be on the lookout for a larger cohort. I do like that the study was randomized. I do like that it was a double-masked study. We need to be able to see reproducible data over a longer period of time with a larger cohort of patients. That is probably already in the makings now. So, I am excited about the concept. And certainly, whatever word I am reaching for, the silver tuna per se, is something that we can do besides just lowering IOP.

Beery: Right.

Casella: And vitamin B3 seems to perhaps have some holding power here, but it shouldn't come below the ocular hypertensive medications that we already prescribe.

Beery: Well, it is always great talking to you, Dr. Casella. Thank you so much for seeing me today. And thank you for this great information.

Casella: You are very welcome. Good to see you, too. Stay safe. Wear a mask, everybody.

Beery: That's right! Wear a mask. Thank you.

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