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.
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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:
- 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.
- 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.
- 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.
- 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/
- Huestis MA. Human cannabinoid pharmacokinetics. Chem Biodivers. 2007;4(8):1770-1804. doi:10.1002/cbdv.200790152https://iovs.arvojournals.org/article.aspx?articleid=2420676
- 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.
- 21214 Rescula Medical Review Part 1 (US Food and Drug Administration).
- 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
- Improved near visual acuity in presbyopes using carbachol and brimonidine eye drops. Trial registered on ANZCTR.
