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Lower is Better המשמעות לפרקטיקה היומיומית

Lower is Better המשמעות לפרקטיקה היומיומית. “Lower Is Better” Proven in Hypertension, Hyperlipedemia and Diabetes. What about in Glaucoma?. Lower Blood Pressure Leads To Better Outcomes. Source: Hypertensiononline.org. Evolution of Hypertension Guidelines (USA). JNC VI *(1997).

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Lower is Better המשמעות לפרקטיקה היומיומית

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  1. Lower is Betterהמשמעות לפרקטיקה היומיומית

  2. “Lower Is Better”Proven in Hypertension, Hyperlipedemia and Diabetes.What about in Glaucoma?

  3. Lower Blood Pressure Leads To Better Outcomes Source: Hypertensiononline.org

  4. Evolution of Hypertension Guidelines (USA) JNC VI *(1997) JNC VII** (2003) *The Sixth Report of the Joint National Committee On Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. NIH Publication November 1997 **The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure NIH Publication No. 04-5230. August 2004

  5. “Lower Is Better” Proven in Hyperlipidemia

  6. The Lower The Cholesterol Levels = The Lower The Risk of CVD Mortality Multiple Risk Factor Intervention Trial (n=350,977) • Elevated serum cholesterol is associated with increased risk of CHD and MI • Re-infarction • Stroke • CVD Mortality • All-cause • CHD • Stroke 50 40 30 CVD mortality rate* 20 10 0 <160 160–199 200–239 >240 Serum cholesterol (mg/dl) *Crude death rate (per 10,000 persons/years) CVD = cardiovascular disease Adapted from Kannel WB Am J Cardiol 1995;76:69C-77C; Anderson KM et al JAMA 1987;257:2176-2180; Kannel WB et al Ann Intern Med 1971;74:1-12; Neaton JD et al Arch Intern Med 1992;152:1490-1500.

  7. The Lower The LDL Levels = The Lower The Risk of CHD Log-linear relationship between LDL-C levels and relative risk for CHD 3.7 –30%CHD risk 2.9 2.2 –30 mg/dl Relative risk for CHD(log scale) 1.7 1.3 1 40 70 100 130 160 190 LDL-C (mg/dl) Grundy et al Recent Clinical Trials and NCEP ATP III

  8. Lower is Better New trends in medical treatment of Systemic Diseases

  9. “Lower Is Better” in Glaucoma Management

  10. IOP is The Most Important Risk Factor in Glaucoma • Both for morbidity & progression • Direct mechanical impact • Vascular damage – Impaired perfusion

  11. Lower is Better For Every Optic Nerve Study IOP Reduction Mean IOP (mmHg) (Treatment vs. No treatment) Progression(Treatment vs.No treatment) EMGT 25% 15.5 vs. 20.6 45% vs. 62% CNTG 30% 20% vs. 60% 10.6 vs. 16.1 CIGTS 37% (Rx) 52% (Surgery) 17 - 18 (Rx)14 - 15 (S) ~ 12% References: EMGT: Heijl et al. Arch Ophthalmol 2002; 120:1268-1279. CNTG: Am j Ophthamol 1998;126:487-497. CIGTS: Lichter et al. Ophthalmolgy 2001; 108:1943-1953

  12. IOP< 18 mmHg = Better Outcomes 0%–50% of Visits <18 mm Hg 50%–75% of Visits <18 mm Hg 75%–100% of Visits <18 mm Hg All Visits <18 mm Hg Mean IOP 20.2 mm Hg 16.9 mm Hg 14.7 mm Hg Mean Change in Visual Defect 12.3 mm Hg AGIS 7. Am J Ophthalmol. 2000.

  13. The Lower The IOP = Less Change in VF Moorfields Glaucoma Study.Ophthalmolgy 1994;101: 1651-1757

  14. Controlled Clinical Trials in Glaucoma Demonstrate That IOP Reduction Reduces The Risk of Visual Field Deterioration at Mean IOP of 12 – 18 mmHg Study Patients N Follow Up (Years) % IOP Reduction Mean IOP (mmHg) EMGT Patients with early glaucoma 255 6 25% 15.5 CNTG Patients with Normal tension Glaucoma 140 8 30% 10.6 17 - 18 CIGTS (Rx) Patients with newly diagnosed open angle glaucoma 607 4 – 5 35% 12.3 AGIS Patients with advanced glaucoma 591 7 35% References: EMGT: Heijl et al. Arch Ophthalmol 2002; 120:1268-1279. CNTG: Am j Ophthamol 1998;126:487-497. CIGTS: Lichter et al. Ophthalmolgy 2001; 108:1943-1953. AGIS: Am j Opthalmol 2000; 130:429-440

  15. Lower is Better - 24h a day • Large diurnal fluctuations in IOP are an independent risk factor in patients with glaucoma1 • IOP fluctuation is larger in eyes with higher IOP levels2 • Optimization of 24 hours IOP is the best goal for minimizing the risk for progressive damage to the optic nerve and visual field3 1.Asrani et al J Glaucoma 2000 2000 Apr;9(2):134-42 2. Bengtson B et al Graefes Arch Clin Exp ophthal 2005 Mar 3. American Journal of Ophthalmology 2002 :133;6;S1-10

  16. דיון מקרה

  17. תיאור מקרה: פרופיל החולה Info • גיל: 56 • מין: זכר • VA : 20/20 בשתי העיניים • C/D Ratio : 0.8 בשתי העיניים • ה- IOP התחלתי - 22 ממ"כ • Normal Anterior Segment

  18. שדה ראייה Exams עין ימין עין שמאל Superior Nasal-Arcuate Defect Mild Inferior Nasal Step

  19. התחלת טיפול בטימולול

  20. מעקב: כעבור שנתיים Info מדידת IOP : • עין ימין - 16 ממ"כ • עין שמאל - 18 ממ"כ

  21. מעקב שדות ראייה: כעבור שנתיים Exams עין ימין עין שמאל

  22. סיכום ביניים Info • לחולה הותחל טיפול בטימולול X2 ביום שהוריד את הלחץ כצפוי • כעבור שנתיים נצפתה הידרדרות בעין שמאל (לחץ – 18 ממ"כ) מה עליי לעשות כעת ?

  23. סיכום ביניים Info • יש להוריד את הלחץ בעין שמאל ל- 15 – 14 ממ"כ • מומלץ לבצע עקומת לחצים

  24. עקומת לחצים(תחת טיפול בטימולול) Exams Mean IOP 15.8 Mean IOP 18

  25. מסקנות: Info • הלחץ מטרה לחולה זה מלכתחילה היה צריך להיות נמוך מ- 18 ממ"כ • בנוסף לכך שהלחץ לא הורד מספיק עקומת לחצים הדגימה פלוקטואציות בלחץ (עלייה בשעות הערב) איזה טיפול היית מתאים לחולה זה? • לחולה נרשם קוסופט – • מדוע קוסופט?

  26. COSOPT Maintained IOP Reduction Up to 9 mmHg Over 15 Months 28 COSOPT (n=112) dorzolamide 2% (n=109)timolol 0.5% (n=110) 26 24 22 IOP 2 hours afteradministration (mmHg) 20 -9mmHg(p<0.05 vs. baseline) 18 17 (-34%) 16 Open extension Double blind 0 1 2 3 6 9 12 15 Week 2 Month p<0.05 for all mean IOP values vs. baseline Adapted from Boyle JE et al Ophthalmology 1998;105(10):1945-1951.

  27. Experience With COSOPT Gained in Swiss Ophthalmologists’ Offices Changes in IOP under COSOPT according to previous therapy at visit 2 compared to baseline. Mean differences between IOP readings at baseline and visit 2 are shown in mmHg BB +CAI** BB + Latanoprost Previouslyon: New Patients Latanoprost BB* Mean Difference in IOP (mmHg) * Topical Beta Blockers ** Carbonic Anhydrase Inhibitors IOP at baseline # of patients: 28.3 23.1 22.3 19.5 20.4 73 165 22 37 134 Adapted from Paijc et. al. Current Medical Research and opinion Vol.19 No.2; 2003: 95-101

  28. COSOPT - Consistent 24 h IOP Control 24-Hour IOP Control • COSOPT provided significantly better IOP control than latanoprost at 10 PM (p=0.006) 18 COSOPT Latanoprost 17 16 15 14 Mean IOP (mmHg) 13 12 11 10 0 2:00 AM 6:00 PM 10:00 PM* 10:00 AM 2:00 PM 6:00 AM *p=0.006 vs. latanoprost Reference: Konstas et.al. Ophthalmolgy 2003; 110: 1357-1360

  29. תודה רבה

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