Topical NSAIDS to stop pain after surgery

[Mike Bartolatz]

Pharmaceutical Corner
Comparing the NSAIDs


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by Matt Young EyeWorld Staff Writer

Less frequent dosing, reduced CME, touted as benefits for patients that complain about ‘that scratchy feeling.’

The U.S. Food and Drug Administration handed down approvals of two new nonsteroidal anti-inflammatory drugs (NSAIDs) this year, and while they may not be vast new improvements over the old, they likely will be helpful.
Nevanac (nepafenac ophthalmic suspension 0.1%, Alcon, Fort Worth, Texas) gained the latest approval, which occurred in August. Xibrom (bromfenac ophthalmic solution 0.09%, ISTA Pharmaceuticals, Irvine, Calif.) was approved in March. Voltaren (diclofenac sodium 0.1%, Novartis, Basel, Switzerland) and Acular (ketorolac tromethamine, Allergan, Irvine, Calif.) are among the frequently used NSAIDS that have been approved for some time.
“They all seem roughly equivalent to me,” said Mark Packer, M.D., Drs. Fine, Hoffman & Packer, Eugene, Ore. “They greatly reduce the incidence of scratchy eyes.”
Other experts point to greater benefits, such as the reduced potential of cystoid macular edema (CME). On that point, Richard L. Lindstrom, M.D., Minnesota Eye Consultants, Minneapolis, said Nevanac appears to have the upper hand.
“It penetrates in a higher concentration deeper into the eye,” Dr. Lindstrom said. “We haven’t yet had a NSAID that actually gets therapeutic concentrations into the posterior segment” to prevent CME.
Meanwhile, Xibrom is used twice a day, said Richard A. Lewis, M.D., Sacramento, Calif., which in terms of dosing is an improvement over Nevanac (a thrice-daily dose) and other NSAIDs, which are used four times daily. Fewer doses are thought to improve compliance. Xibrom also doesn’t sting upon application, which isn’t the case will all NSAIDS, he said.

Considering the differences

Inflammation after cataract surgery involves both the cyclooxygenase and lipoxygenase pathways. Ophthalmologists have said that the lipoxygenase pathway leads to the creation of leukotrienes, certain physiologically active mediators of inflammation. The cyclooxygenase pathway contributes more to other kinds of inflammatory reactions that catalyze the conversion of arachidonic acid to prostaglandins.
Steroids block both pathways, but ophthalmologists have said that they do not block the cyclooxygenase pathway as specifically and as quickly as NSAIDs, which accounts for the popularity of NSAIDs.
But do the new NSAIDs add much value to the nonsteroidal marketplace?
“At this point, the marketing for these new products is quite strong, but we do not have substantive data to prove any real superiority,” said Louis D. "Skip" Nichamin, M.D., medical director, Laurel Eye Clinic, Brookville, Pa.
Alcon has said that in clinical trials, more than 80% of patients treated with Nevanac were pain free the day after surgery, compared with less than 50% in a placebo group where NSAIDs were not used. Following two weeks of Nevanac treatment, about 95% of patients were pain free compared with 45% of patients in the placebo group, the company reported.
“But at the end of the day you have to run prospective randomized comparative studies to see if one drug is better than the other,” Dr. Nichamin said. “I have a feeling that we’ll just have more NSAID choices now. That’s good. A lot of times doctors acquire medicines through bundled packages so they prefer to work with one company over another.”
Dr. Lindstrom sees Nevanac differently.
“The anticipation is that it will do a better job in preventing and treating CME,” Dr. Lindstrom said. “We don’t have head-to-head studies yet to show that it is going to be superior to Voltaren or Acular in a clinical trial but we do have data that shows it penetrates to the target tissue better.”
Dr. Lindstrom also said Nevanac penetrates into the anterior segment better, which leads to less pain and inflammation.
Dr. Packer said he hasn’t thought about the issue of NSAID penetration much because CME doesn’t occur often—probably less than in 1% of his practice’s cases. He also said “pain” after cataract surgery is not a throbbing one, but simply more of a foreign-body sensation. However, NSAIDs do prevent that sensation, which detracts from the incredible enjoyment of suddenly having 20/20 vision, he said.
“I try to get them to focus on that but they keep talking about the scratchy feeling,” Dr. Packer said.
“But by routinely using an NSAID for the first couple of weeks after cataract surgery, patients will find that feeling virtually disappears,” Dr. Packer said.

Editors’ note: Dr. Lewis is a consultant for ISTA Pharmaceuticals. Dr. Lindstrom is a consultant for Alcon. Dr. Nichamin has a finalcial interest in Baush & Lomb and Refractec. Dr. Packer has no financial interests related to his comments.

Contact Information:
Lewis: 916-455-9938, rlewismd@pacbell.net
Lindstrom: 612-813-3633, rllindstrom@mneye.com
Nichamin: 814-849-8344, Nichamin@laureleye.com
Packer: 541-687-2110, mpacker@finemd.com