Ophthalmic Anti-Inflammatories Therapeutic Class Review (TCR) October 20, 2020 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, digital scanning, or via any information storage or retrieval system without the express written consent of Magellan Rx Management. All requests for permission should be mailed to: Magellan Rx Management Attention: Legal Department 6950 Columbia Gateway Drive Columbia, Maryland 21046 The materials contained herein represent the opinions of the collective authors and editors and should not be construed to be the official representation of any professional organization or group, any state Pharmacy and Therapeutics committee, any state Medicaid Agency, or any other clinical committee. 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FDA-APPROVED INDICATIONS Drug Manufacturer Indication(s) Corticosteroids – Ophthalmic Topical dexamethasone (Maxidex®)1 Alcon/Novartis . Treatment of corticosteroid-responsive inflammatory conditions of the palpebral and bulbar conjunctiva, cornea, and anterior segment of the globe . Corneal injury dexamethasone sodium Valeant/Bausch . Treatment of corticosteroid-responsive inflammatory conditions of phosphate2 the palpebral and bulbar conjunctiva, cornea, and anterior segment of the globe . Corneal injury difluprednate (Durezol®)3 Alcon/Novartis . Treatment of inflammation and pain associated with ocular surgery . Treatment of endogenous anterior uveitis fluorometholone suspension Allergan, Pacific/ . Treatment of corticosteroid-responsive inflammatory conditions of (FML®)4 Greenstone* the palpebral and bulbar conjunctiva, cornea, and anterior segment of the globe fluorometholone Allergan . Treatment of corticosteroid-responsive inflammatory conditions of (FML Forte®)5 the palpebral and bulbar conjunctiva, cornea, and anterior segment of the globe fluorometholone ointment Allergan . Treatment of corticosteroid-responsive inflammatory conditions of (FML S.O.P.®)6 the palpebral and bulbar conjunctiva, cornea, and anterior segment of the globe fluorometholone acetate Alcon/Eyevance . Treatment of corticosteroid-responsive inflammatory conditions of (Flarex®)7 the palpebral and bulbar conjunctiva, cornea, and anterior segment of the globe loteprednol 1% suspension Kala . Treatment of post-operative inflammation and pain following (Inveltys®)8 ocular surgery loteprednol 0.5% gel Valeant/Bausch . Treatment of post-operative inflammation and pain following (Lotemax®)9 ocular surgery loteprednol 0.5% ointment Valeant/Bausch . Treatment of post-operative inflammation and pain following (Lotemax®)10 ocular surgery loteprednol 0.5% suspension generic, . Treatment of corticosteroid-responsive inflammatory conditions of (Lotemax®)11 Valeant/Bausch the palpebral and bulbar conjunctiva, cornea, and anterior segment of the globe . Treatment of post-operative inflammation following ocular surgery loteprednol 0.38% gel Valeant/Bausch . Treatment of post-operative inflammation and pain following (Lotemax® SM)12 ocular surgery prednisolone acetate 1% Alcon/Novartis, . Treatment of corticosteroid-responsive inflammatory conditions of (Omnipred®)13 Sandoz* the palpebral and bulbar conjunctiva, cornea, and anterior segment of the globe . Treatment of corneal injury prednisolone acetate 1% Allergan, Pacific/ . Treatment of corticosteroid-responsive inflammatory conditions of (Pred Forte®)14 Greenstone* the palpebral and bulbar conjunctiva, cornea, and anterior segment of the globe prednisolone acetate 0.12% Allergan . Treatment of mild to moderate noninfectious allergic and (Pred Mild®)15 inflammatory disorders of the lid, conjunctiva, cornea, and sclera (including chemical and thermal burns) prednisolone sodium Valeant/Bausch . Treatment of inflammatory conditions of the palpebral and bulbar phosphate16 conjunctiva, cornea, and anterior segment of the globe . Corneal injury * Authorized generic Ophthalmic Anti-Inflammatories Review – October 2020 Page 2 | Proprietary Information. Restricted Access – Do not disseminate or copy without approval. © 2004-2020 Magellan Rx Management. All Rights Reserved. FDA-Approved Indications (continued) Drug Manufacturer Indication(s) Corticosteroids – Implants, Inserts, or Injections dexamethasone suspension Eyepoint . Treatment of post-operative inflammation (Dexycu®)17 dexamethasone implant Allergan . Treatment of macular edema following branch retinal vein (Ozurdex®)18 occlusion (BRVO) or central retinal vein occlusion (CRVO) . Treatment of non-infectious uveitis affecting the posterior segment of the eye . Treatment of diabetic macular edema dexamethasone insert Ocular Therapeutix . Treatment of ocular pain and inflammation following ophthalmic (Dextenza®)19 surgery fluocinolone 0.18 mg Eyepoint . Treatment of chronic non-infectious uveitis affecting the (Yutiq®)20 posterior segment of the eye fluocinolone 0.19 mg Alimera . Treatment of diabetic macular edema in patients who have been (Iluvien®)21 previously treated with a course of corticosteroids and did not have a clinically significant rise in intraocular pressure fluocinolone 0.59 mg Valeant/Bausch . Treatment of chronic non-infectious uveitis affecting the (Retisert®)22 posterior segment of the eye triamcinolone acetonide Alcon/Novartis . Treatment of sympathetic ophthalmia, temporal arteritis, uveitis, (Triesence®)23 and ocular inflammatory conditions unresponsive to topical corticosteroids . Visualization during vitrectomy NSAIDs bromfenac 0.07% Valeant/Bausch . Treatment of post-operative inflammation and reduction of (Prolensa®)24 ocular pain secondary to cataract extraction/surgery† bromfenac 0.075% Sun (Bromsite®)25 bromfenac 0.09%26 generic diclofenac sodium27 generic . Treatment of post-operative inflammation secondary to cataract extraction . Temporary relief of pain and photophobia in patients undergoing corneal refractive surgery flurbiprofen sodium28 Amici . Inhibition of intraoperative miosis ketorolac 0.4% (Acular LS®)29 Allergan, . Reduction of ocular pain, burning, and stinging after corneal Pacific/Greenstone* refractive surgery ketorolac 0.45% (Acuvail®)30 Allergan . Treatment of pain and inflammation following cataract surgery ketorolac 0.5% (Acular®)31 generic, Allergan . Treatment of inflammation following cataract surgery‡ nepafenac 0.3% (Ilevro®)32 Alcon/Novartis . Treatment of pain and inflammation associated with cataract nepafenac 0.1% (Nevanac®)33 Alcon/Novartis surgery * Authorized generic † Bromsite is approved for the treatment of post-operative inflammation and prevention of ocular pain in patients undergoing cataract surgery. ‡ Ketorolac 0.5% ophthalmic solution (Acular®) is also indicated for the temporary relief from ocular itching related to seasonal allergic conjunctivitis. Loteprednol ophthalmic suspension 0.2% (Alrex®) is indicated for the temporary relief of signs and symptoms of seasonal allergic conjunctivitis and is not included in this therapeutic class review. Ophthalmic Anti-Inflammatories Review – October 2020 Page 3 | Proprietary Information. Restricted Access – Do not disseminate or copy without approval. © 2004-2020 Magellan Rx Management. All Rights Reserved. OVERVIEW Uveitis is an inflammation of the middle layer of the eye or uvea, consisting of the iris, ciliary body, and choroid.34,35 Uveitis may be caused by eye trauma, may be secondary to autoimmune diseases or infection, or may be idiopathic in nature.36 It may present as acute, chronic, or recurrent attacks, with unilateral pain or photophobia.37 Aqueous cells and flare, due to cellular infiltration and protein exudation into the anterior chamber, are seen as spots and haze on slit-beam examination; both are signs of ocular inflammation. If left untreated, uveitis can lead to glaucoma, cataract, or retinal edema and ultimately loss of vision. Initial treatment for uveitis typically includes ophthalmic corticosteroids to reduce pain and inflammation. Temporal arteritis, affecting the superficial temporal arteries, is a systemic inflammatory vasculitis of unknown etiology that occurs in older individuals and can result in systemic, neurologic, and ophthalmologic complications.38 Permanent visual impairment is estimated in up to 20% of patients with the condition. Timely initiation of therapy may prevent irreversible damage, including blindness. The mainstay of therapy includes corticosteroids, which are typically prescribed for up to 2 years. To ensure its transparency, the cornea is maintained in a dehydrated state by the pumping action of the endothelial cells controlled by Na+/K+-ATPase.39 Damage to the corneal endothelium may result in increased