Efficacy and safety of different regimes for primary open-angle glaucoma or ocular hypertension: A systematic review and network meta-analysis

Methodological quality of the review: Medium Confidence

Authors: Li F, Huang W, Zhang X

Region: Not specified

Sector: Glaucoma

Sub-sector: None specified

Equity focus: None specified

Review type: Other review

Quantitative synthesis method, if applicable: meta-analysis

Qualitative synthesis method, if applicable: Not applicable

Background:

Medical treatments act to decrease intraocular pressure (IOP) in three main ways: increase outflow of aqueous humour, decrease secretion of aqueous humour and decrease intra-ocular volume. Prostaglandins (PGA), adrenergic agonists (AA), beta‐blockers (BB), carbonic anhydrase inhibitors (CAI) and miotics (MIO) are the drugs most widely used to treat primary open-angle glaucoma (POAG). Previous meta-analyses have compared the IOP lowering efficacy of drugs such as latanoprost and timolol, among others, but these comparisons have been carried out between only a limited number of regimens because data from randomized controlled trials involve limited types of drugs. A previous network meta-analysis compared the treatment effect of several PGAs, AAs, BBs and placebo, but its data focused on comparisons among the use of single drugs. To elucidate the IOP lowering effect of different categories and combinations of drugs, this study describes a network meta-analysis comparing and ranking all categories of medications for medical treatment of POAG.

Objectives:

To assess the efficacy and safety of different regimens, including monotherapy and double therapy, for primary open-angle glaucoma (POAG) or ocular hypertension.

Main findings:

The authors’ meta-analysis showed that PGAs provide best IOP-lowering effect among all the monotherapy regimen. Combination of PGA and other category of drugs leads to better IOP decrease. Combination of BB and another non-PGA drug may have less ocular side-effects than PGA alone.

This study includes 72 randomized trials. Data were available on 12 medical treatments of POAG or ocular hypertension. Of 66 possible comparisons of outcome efficacy, 15 treatments were compared directly.

Considering the complex comparison network between all regimens, using meta-regression or subgroup analysis to check the bias may not be helpful. Future studies are needed to determine whether these factors have substantial influence on treatment outcomes.

Methodology:

Studies were included in this review based on the following criteria.

• Studies must be randomized controlled trials.
• Trials must compare the above-mentioned antiglaucoma regimens in glaucoma patients.
• Duration of trials must be at least 3 months.
• Different categories or combinations of medicines must be used in different groups of patients, and only one type of regimen can be used during the trial by one group of patients.
• Trials must report on the outcomes of interest.

The authors searched PubMed, EMBASE and clinicaltrials.gov for studies that fit our inclusion criteria in this network meta-analysis. Randomized controlled trials that report data on efficacy and safety of medications for POAG or ocular hypertension are included. Data on IOP-lowering effect and incidence of adverse events including hyperaemia and ocular discomfort were extracted and used in mixed-comparison analysis.

Applicability/external validity:

In clinical practice, when considering regimens for IOP lowering, not only the IOP-lowering efficacy but also the incidence of adverse events should be considered.

Geographic focus: None specified

Summary of quality assessment:

The authors here do not state whether they made attempts to contact the authors of the studies. They do however include all other information, albeit in the form of supplementary tables that can be accessed via the online version of the article, for this reason it is awarded Medium Confidence