Sumatriptan identified as highest-risk drug leading to acute angle-closure glaucoma

Various drugs have been reported to cause acute angle-closure glaucoma, a sight-threatening disease that causes irreversible damage to the optic nerves. It occurs when intraocular pressure rises rapidly due to abrupt occlusion of the anterior chamber angle, which is a pathway for the aqueous humour to exit the eyeball. Other risk factors associated with angle closure are older age, female sex, Asian ancestry and a shallow anterior chamber.1 Understanding the association of drugs with acute angle-closure is important in preventing the condition. However, to date, no risk assessment has been accurately performed for most drugs associated with acute angle-closure.1 To examine this issue, a new Korean study sought to identify drugs that are associated with acute angle-closure glaucoma occurrence and to evaluate the degree of risk with each drug. The case-crossover study used a health insurance database containing medical information for the entire population of Korea.1 Using diagnostic and procedure codes, the investigators identified patients who were first diagnosed with acute angle-closure from 2013 to 2019. They also identified all drugs that the study participants were prescribed during the 180-day period before the onset of acute angle-closure. For each patient, one to 30 days before the onset of acute angle-closure was considered the hazard period, and 91–180 days before onset was considered the control period.1 For each drug identified as being associated with acute angle-closure, the investigators determined the odds ratio (OR) with 95% confidence interval (CI) for acute angle-closure development.1 Results showed the following: A total of 949 drugs were prescribed to 13,531 patients with acute angle-closure during the 180-day period before the onset of acute angle-closure. A total of 61 drugs were found to be associated with acute angle-closure. For the 61 drugs, the median period from prescription of the drug to the onset of acute angle-closure was 11.9 days. Sumatriptan (OR, 12.60 [95% CI, 4.13–38.44]) was associated with the highest odds of acute angle-closure development, followed by topiramate (OR, 5.10 [95% CI, 2.22–11.70]) and duloxetine (OR, 4.04 [95% CI, 2.95–5.54]). A variety of other drugs also showed associations with the development of acute angle-closure, including amitriptyline, nortriptyline, escitalopram, alprazolam, buspirone, diazepam, antihistamines and pseudoephedrine (see complete list of drugs in the article). Some drugs not previously considered to be associated with acute angle-closure were also identified, including lactulose (OR, 2.81 [95% CI, 1.72–4.61]) and metoclopramide (OR, 2.52 [95% CI, 1.95–3.25]). In this study, 36.6% of patients with acute angle-closure had drug-associated acute angle-closure.1 The authors conclude that the risk of acute angle-closure needs to be considered in patients taking any of the 61 drugs found in this study to be associated with acute angle-closure.1 An accompanying commentary stresses the importance of considering the magnitude of risk of acute angle-closure. The authors point out that the risk of developing acute angle-closure in someone with an anatomically predisposed anterior chamber angle is less than one in 1000 over one year. As most of the odds ratios in the Korean study were around 2, the absolute risk to an individual in the the general population with acute angle-closure will be extremely small (~1 in 500 over 1 year) if they receive a medication that doubles their risk of acute angle-closure.2 The commentary also highlights that many drugs with recognized associations with acute angle-closure offer important benefits to patients, and patients should not be deprived of these medications because of a very small increase in acute angle-closure risk. The authors of the commentary suggest that the prescribing physician should warn patients of the very small possibility of acute angle-closure, explain the symptoms, and instruct patients to seek urgent ophthalmological care if they occur. Some patients warrant a more proactive approach. For example, individuals with suspected primary angle closure should be offered prophylactic peripheral iridotomy. All adults should be encouraged to have regular ophthalmic examinations by an eye care professional.2 References 1. Na KI, Park SP. Association of drugs with acute angle closure. JAMA Ophthalmol 2022;140(11):1055-63. (accessed November 22, 2022). 2. Foster PJ, Luben R, Khawaja AP. Examining the role of systemic medications in the onset of acute angle-closure episodes. JAMA Ophthalmol 2022;140(11):1064-5. (accessed November 22, 2022).

Sumatriptan identified as highest-risk drug leading to acute angle-closure glaucoma

Register for free access or login.

Related Topics