Rhopressa (netarsudil) is a prescription eye drop used to lower elevated intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension. As a newer class of medication known as a rho kinase (ROCK) inhibitor, it offers a different mechanism of action than older glaucoma drugs. However, like all medications, it comes with a range of potential issues that patients and healthcare providers must consider. These problems range from common and bothersome side effects to significant barriers related to cost and accessibility.
Common and High-Incidence Ocular Side Effects
The most frequently reported problems with Rhopressa involve its effects on the eyes. Clinical trial data revealed several common adverse reactions, many of which can impact a patient's comfort and willingness to continue treatment.
- Conjunctival Hyperemia (Eye Redness): This is the most prevalent side effect, reported in over half (53%) of patients during clinical trials. While the redness is often mild to moderate and may diminish over time, it can be persistent and bothersome enough to cause some patients (6% in trials) to discontinue the medication. This cosmetic side effect can be a significant concern for those who are self-conscious about their appearance.
- Corneal Verticillata (Corneal Deposits): Approximately 20% of patients experience this side effect, which presents as tiny deposits on the surface of the cornea. These deposits typically do not affect visual function and are reversible upon stopping treatment. However, their presence highlights a known physiological effect of the drug.
- Instillation Site Pain: Pain or discomfort when applying the eye drops was reported in up to 20% of patients. This can affect patient compliance, particularly if the stinging or burning sensation is severe or persistent.
- Conjunctival Hemorrhage: Small, broken blood vessels on the white of the eye were also reported in approximately 20% of patients. These are typically mild and self-limiting.
Significant Access and Tolerability Issues
Beyond direct ocular effects, several systemic and practical problems affect the use of Rhopressa. These factors often play a crucial role in a patient's long-term success with the medication.
High Cost and Insurance Coverage Challenges
One of the most significant barriers to using Rhopressa is its high cost. As a brand-name medication with no generic alternative, the price remains high. While some insurance plans may offer coverage, patients often face high co-pays or face step-therapy requirements, where they must fail on cheaper alternatives first. A study noted that cost could limit utility, even with insurance, and presented a major obstacle for those without adequate coverage. For many, the financial burden makes consistent, long-term adherence unfeasible.
Impact on Adherence
The combination of cost and tolerability issues can lead to poor patient adherence. Discontinuation rates due to side effects are not insignificant. In one real-world study, almost 12% of patients withdrew from treatment due to adverse effects, and less than half of the patients who filled a prescription continued using it long-term. This lack of sustained usage can compromise the medication's therapeutic benefit for managing glaucoma.
Corneal and Contamination Risks
- Epithelial Corneal Edema: Some patients, especially those with pre-existing corneal conditions or recent eye surgery, have reported epithelial corneal edema. This can cause eye pain and decreased vision, though it generally resolves after stopping the medication. There are even rare case reports of this happening in patients with otherwise healthy corneas.
- Bacterial Keratitis: The use of multi-dose ophthalmic products carries a risk of contamination. If the dropper tip touches the eye or other surfaces, it can transfer bacteria, potentially leading to a serious eye infection called bacterial keratitis. Proper handling is critical, and patients must be vigilant to avoid contamination.
Contact Lens Complications
Rhopressa contains benzalkonium chloride, a preservative that can be absorbed by soft contact lenses. To prevent potential lens damage and irritation, patients must remove their soft contact lenses before instilling the drops and wait at least 15 minutes before reinserting them. This requirement can be inconvenient for contact lens wearers.
Comparison of Rhopressa and Other Glaucoma Medications
It is helpful to compare the problems associated with Rhopressa to those of other common glaucoma medications. The following table contrasts Rhopressa with prostaglandin analogs (like Latanoprost) and beta-blockers (like Timolol).
| Feature | Rhopressa (Netarsudil) | Prostaglandin Analogs (e.g., Latanoprost) | Beta-Blockers (e.g., Timolol) |
|---|---|---|---|
| Mechanism | Increases aqueous outflow via trabecular meshwork (ROCK inhibitor) | Increases uveoscleral outflow | Decreases aqueous humor production |
| Common Ocular Side Effects | High incidence of conjunctival hyperemia, corneal deposits (verticillata), instillation pain, conjunctival hemorrhage | Redness, eyelash growth, iris color change | Stinging on application, dry eyes |
| Systemic Side Effects | Minimal, low systemic absorption | Generally minimal, but potential for systemic effects is low | Cardiovascular and respiratory effects (e.g., bradycardia, shortness of breath, wheezing) |
| Cost | High, brand-name only; cost and insurance coverage are major hurdles | Varies; many generic versions are available and affordable | Low, generic versions widely available |
| Contact Lenses | Requires removal for 15 minutes due to preservative | Preservatives can affect lenses; removal often required | Contains preservatives; removal often required |
| Adherence Challenges | Significant, due to high side effect burden and cost | Generally good; cosmetic changes can be bothersome | Generally good; potential systemic effects can impact compliance |
Conclusion
While Rhopressa provides a valuable, new therapeutic option for reducing intraocular pressure, it is not without its drawbacks. The most pressing problems with Rhopressa include its high rate of ocular side effects, particularly conjunctival hyperemia and corneal verticillata, which can significantly impact a patient's willingness to continue treatment. Furthermore, its high cost and lack of a generic option create substantial access and adherence challenges. For patients with pre-existing corneal issues, there is an added risk of epithelial corneal edema, and all users must practice proper hygiene to prevent bacterial keratitis. Though it may be an effective adjunct therapy, its tolerability and cost must be carefully weighed against the benefits, and alternative, often more affordable, options should be considered. Patients should maintain open communication with their ophthalmologist and report any adverse effects immediately.
For more detailed prescribing information, consult the official FDA documentation for netarsudil ophthalmic solution.
