Marguerite McDonald, MD, FACS: Let’s talk a little about lifitegrast and its role in your practice. Are you using it?
Richard Mangan, OD, FAAO: I use it quite a bit, actually. I have to say overall, it’s been well received by my patients. It has a couple extra [adverse] effects we are aware of, like dysgeusia and blurred vision. I find that those are real in my practice, but again, by educating patients ahead of time on these, I’ve yet to have any patient stop the medicine because of the dysgeusia. I think I’ve had 1 out of many patients stop it because of extended blurred vision. I don’t know if you’ve experienced that in your practice. But comfort wise, it’s been overall really positive.
Marguerite McDonald, MD, FACS: How about you, Eric?
Eric Donnenfeld, MD, FACS: In the FDA trials, dysgeusia, bad taste in your mouth, was a pretty common complaint. In my clinical practice, it really hasn’t been that much of an issue. I really haven’t seen it that commonly. I tell patients about it sometimes, but I haven’t really worried about it.
Like all dry eye medications, when you’re putting a medication onto an ocular surface that’s been traumatized by dry eye, you’re going to have [adverse] effects because this eye doesn’t react normally. You’re going to have more irritation, more redness, and very commonly, the first stage of return of tear film function is a return of innervation and return of corneal sensation.
Dry eye patients are anesthetic. When they start getting better, it’s like when your foot goes numb and you don’t feel anything, that’s the dry eye state. Then the sensation starts coming back and you start getting pain. That’s what happens in your eyes. You have to live through that for a couple weeks and you come out the other side.
Although it is not FDA approved, I very commonly will combine immunosuppression or immunomodulation with lifitegrast or cyclosporine with a topical corticosteroid. The topical corticosteroid is very rapidly acting, very efficacious. You can’t keep patients on it for a long time, but a month of combination therapy will very commonly get patients over that hump to become more comfortable so they can stay on immunosuppressive therapy for longer periods.
Marguerite McDonald, MD, FACS: I have a quick little lifitegrast speech that I give and that I’m convinced has increased compliance and prevented calls. I tell patients that the vast majority of people tolerate it beautifully. If you have a bad taste in your mouth 5 minutes later, nothing is wrong—it’s important to say that—just brush your teeth, use mouthwash, or chew a piece of sugar-free gum. I tell them if there’s a little discomfort on instillation, put the medication in the refrigerator. When it’s cold, it will feel much better. I say if it is still bothersome, first put in a cold preservative-free tear from the refrigerator followed immediately by the cold lifitegrast. If patients have blurring, I say, put the drop in your eye the minute you swing your feet out of bed in the morning and then go do some non-critical task like make breakfast or take a shower or whatever. By the time you go to work, you should be seeing well.
Rarely do you have somebody who has blurring for more than 30 minutes, in which case I say, okay, just use the medication at night. They’ll get their therapeutic effect but slower.
I really love lifitegrast because it is fast. The onset of action is fast enough that in a surgical practice you can really tune people up and get them ready for surgery pretty much faster than with any other prescription drug right now.
Eric Donnenfeld, MD, FACS: The FDA trial showed the rapidity of action and that a number of patients actually showed clinically significant improvement in 2 weeks, which is really pretty extraordinary.
Richard Mangan, OD, FAAO: It is.
Eric Donnenfeld, MD, FACS: I think Marguerite’s point is well taken. When patients come into a surgical practice, whether you’re co-managing it or doing the surgery yourself, the patient doesn’t want to wait 2 or 3 months before they’re ready for surgery. You want to make sure that patients can come back in 2 or 3 weeks and be ready to go.
Lifitegrast is part of my rapid action management for dry eye patients having surgery, so that I can get these patients into the operating room the same month.