Here’s the Washout Period for Each Glaucoma Medication

by Bruce Colton, OD, Sierra Vogt Suarez, OD, and Iqra Quddus, OD
Jun 2, 2021
6 min read
523 views

Sometimes a clinician will need to discontinue a patient’s glaucoma medications just long enough to get a baseline IOP, and then build a fresh plan for IOP control. But how long after discontinuing glaucoma medication does the IOP confidently reach baseline levels?

The answer is a confusing smear of a bell curve, different for every patient depending on their kidney and liver function, concurrent systemic medications, and type of glaucoma. We reviewed dozens of peer-reviewed journals and FDA approval reports to bring you an easy-to-use simplified clinical washout period for each glaucoma medication. If you would like to delve deeper into the complicated world of absorption and clearance rates, blood and plasma concentrations vs lingering clinical effects, standard deviations, chemical half-life, and confounding variables, our best source references are listed at the end of the article.

Want this list as a cheat sheet? Download it here!

Prostaglandins

Brand Name Generic Name Washout Period
Lumigan 0.01% Bimatoprost soln 4.5 weeks
Lumigan 0.03% Bimatoprost soln 4.5 weeks
Travatan 0.004% Travoprost soln 4.5 weeks
Travatan Z 0.004% Travoprost soln 4.5 weeks
Zioptan 0.0015% Tafluprost soln 4.5 weeks
Xalatan 0.005% Latanoprost 4.5 weeks
Rescula 0.15% Unoprostone soln 4 weeks
Vyzulta 0.024% Latanoprostene Bunod soln 4.5 weeks

Beta-Blockers

Brand Name Generic Name Washout Period
Timoptic 0.25% Timolol soln 4 weeks
Timoptic 0.5% Timolol soln 4 weeks
Timoptic XE 0.25% Timolol Gel-Forming soln 4 weeks
Timoptic XE 0.5% Timolol Gel-Forming soln 4 weeks
Timoptic Ocudose PF 0.25% Timolol soln 4 weeks
Timoptic Ocudose PF 0.5% Timolol soln 4 weeks
Betoptic 0.5% Betaxolol soln 4 weeks
Betoptic S 0.25% Betaxolol soln 4 weeks
Betagan 0.25% Levobunolol soln 4 weeks
Betagan 0.5% Levobunolol soln 4 weeks
Optipranolol 0.3% Metipranolol soln 4 weeks

Alpha-Agonists

Brand Name Generic Name Washout Period
Alphagan 0.15% Brimonidine soln 5 weeks
Alphagan P 0.15% Brimonidine soln 5 weeks
Alphagan 0.2% Brimonidine soln 5 weeks
Iopidine 0.5% Apraclonidine soln 5 weeks
Iopidine 1% Apraclonidine soln 5 weeks

Muscarinic Agonists

Brand Name Generic Name Washout Period
Isopto Carpine 1% Pilocarpine soln 3 days
Isopto Carpine 2% Pilocarpine soln 3 days
Isopto Carpine 4% Pilocarpine soln 3 days

Rho-Kinase Inhibitors

Brand Name Generic Name Washout Period
Rhopressa 0.02% Netarsudil soln 4 weeks

Carbonic Anhydrase Inhibitors

Brand Name Generic Name Washout Period
Azopt 1% Brinzolamide susp 1 week
Trusopt 2% Dorzolamide soln 1 week
Trusopt PF 2% Dorzolamide soln 1 week
Diamox Sequels 500mg Acetazolamide ER tablet 1 week

Osmotic Diuretics

Brand Name Generic Name Washout Period
Osmitrol 20% Mannitol soln (oral or IV) 1 week

Cannabinoids

Brand Name Generic Name Washout Period
THC Tetrahydrocannabinol (THC) 4 days
Marinol Dronabinol (synthetic THC) 4 days
  • Note: CBD (Cannabidiol) raises IOP even higher, so CBD does not treat glaucoma.

Fixed-Combination Medications

Brand Name Generic Name Washout Period
Cosopt Timolol + Dorzolamide soln 4 weeks
Cosopt PF Timolol + Dorzolamide soln 4 weeks
Combigan Timolol + Brimonidine soln 5 weeks
Simbrinza Brimonidine + Brinzolamide susp 5 weeks
DuoTrav Timolol + Travoprost 4.5 weeks
Xalacom Timolol + Latanoprost 4.5 weeks
Rocklatan Netarsudil + Latanoprost 4.5 weeks

Occasionally, we need a glaucoma patient to discontinue all their IOP medications so we can measure a confident baseline and establish which medications are effective for them.

Educate the patient on the following:

  • They will still need to be treated with IOP medications afterward.
  • Even though a high IOP can cause vision loss long-term, the brief timeline of the washout period should not cause any vision loss.
  • During the washout period, if they experience any discomfort or change in vision they should return to the clinic immediately.

Navigating the washout period for ocular hypotensive medication in research can be very frustrating. Different authors will publish conflicting findings for the same medications. As a frontline clinician, you must decide how to use the data—will your washout time match when 50% of similar patients have returned to baseline, or 90%, or 99%? The difference can mean many weeks or months of your patient leaving their eye pressure untreated. Our published guidelines reflect a marriage between the cold, hard science of drug washout and the industry-accepted, standard-of-care timelines. However you choose to manage your patient’s washout, make sure that your confidence is evidence-based and your patient understands your long-term plan.

References:

  1. Diaconita V, Quinn M, Jamal D, Dishan B, Malvankar-Mehta MS, Hutnik C. Washout Duration of Prostaglandin Analogues: A Systematic Review and Meta-analysis. J Ophthalmol. 2018 Sep 27;2018:3190684. doi: 10.1155/2018/3190684. PMID: 30363694; PMCID: PMC6180964.
  2. Leary KA, Lin KT, Steibel JP, Harman CD, Komáromy AM. Safety and efficacy of topically administered netarsudil (Rhopressa™) in normal and glaucomatous dogs with ADAMTS10-open-angle glaucoma (ADAMTS10-OAG). Vet Ophthalmol. 2021 Mar;24 Suppl 1(Suppl 1):75-86. doi: 10.1111/vop.12734. Epub 2019 Dec 24. PMID: 31872953; PMCID: PMC7755039.
  3. Stewart WC, Holmes KT, Johnson MA. Washout periods for brimonidine 0.2% and latanoprost 0.005%. Am J Ophthalmol. 2001 Jun;131(6):798-9. doi: 10.1016/s0002-9394(00)00930-2. PMID: 11384581.
  4. Diaconita V, Quinn M, Jamal D, Dishan B, Malvankar-Mehta MS, Hutnik C. Washout Duration of Prostaglandin Analogues: A Systematic Review and Meta-analysis. J Ophthalmol. 2018 Sep 27;2018:3190684. doi: 10.1155/2018/3190684. PMID: 30363694; PMCID: PMC6180964.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2636120/
  5. Huestis MA. Human cannabinoid pharmacokinetics. Chem Biodivers. 2007;4(8):1770-1804. doi:10.1002/cbdv.200790152https://iovs.arvojournals.org/article.aspx?articleid=2420676
  6. Weinreb, Robert N. et al. 24-Hour Intraocular Pressure Control with Fixed-dose Combination Brinzolamide 1%/Brimonidine 0.2%. Ophthalmology, Volume 126, Issue 8, 1095 - 1104.
  7. 21214 Rescula Medical Review Part 1 (US Food and Drug Administration).
  8. Konstas, A., Katsimpris, I., Kaltsos, K. et al. Twenty-four-hour efficacy of the brimonidine/timolol fixed combination versus therapy with the unfixed components. Eye 22, 1391–1397 (2008). https://doi.org/10.1038/sj.eye.6702906
  9. Improved near visual acuity in presbyopes using carbachol and brimonidine eye drops. Trial registered on ANZCTR.
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About Bruce Colton, OD

Bruce Colton, O.D. earned his degrees from BYU and UHCO, where he taught Microbiology and did stem cell research with the NIH to help cure macular degeneration. He opened Bright Eyes Vision Clinic near Dallas, TX in 2017, which he …

About Sierra Vogt Suarez, OD

Sierra Vogt Suarez, OD, earned her degrees at The University of Iowa and ICO. Due to her husband's career with the Air Force, Dr Suarez has worked in private practices in South Carolina, New Jersey, and Oklahoma. She most recently …

About Iqra Quddus, OD

Iqra Quddus, OD, earned her degrees at Stony Brook University in New York and UHCO. She graduated UHCO in May 2018 and has practiced in both NY and currently practices at Bright Eyes Vision Clinic in Murphy, TX.  She most …

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