If you have dry eye, at some point your doctor has probably mentioned Restasis.  I was recently told that Restasis is the most commonly prescribed pharmaceutical eye drop, and that statement doesn't surprise me in the least.  For patients suffering from dry eye, over the counter artificial tears are not always enough to relieve the signs and symptoms of dryness.  If you are having to use over the counter artificial tears routinely more than four to six times a day, then you are in need of more advanced intervention to treat your dry eye.  Restasis is the next step for many doctors, but there is a lot to understand about this drop.

1) When to use Restasis
Depending on who you ask, you are going to get different answers to this question.  Personally, I always treat meibomian gland issues (see this post) first with a combination of warm compresses, lid hygeine, and artificial tears as needed. If the glands start responding to treatment and the patient still is having complaints (dryness, watering, grittiness, sharp pain, etc), I offer punctal plugs or Restasis as the next therapy line.  You will have some doctors tell you that Restasis is best used on post-menapausal women, but I have seen it be effective in men as well, and there is no scientific evidence as of yet to limit the use to a certain population base.  In short, if tears and MGD treatment isn't resolving things, it is time to consider Restasis.



2) How Restasis Works

Vials come in trays, with 1 tray equal to 2 weeks technically, but really this amount will last 1 month if you recap.

I asked this question to my Allergan rep just last week, and he just gave me the simplest answer: "we don't know yet."   What we do know is that Restasis is cylcosporine (a potent anti-inflammatory that has been used in organ transplants in a different concentration).  The goal of this anti-inflammatory is to stop the production of T cells which are inflammatory mediators that are naturally in your tear film.  Chronically dry eyes have these T cells in higher concentration than normal eyes.  Point of interest: the T cell has a lifespan of 180 days, so Restasis should take 3 months to begin to effectively work.  Restasis also helps increase the production of tears, but how this happens is not effectively understood.

3) How to Write the Rx
Allergan provides an Advantage Pack with a card that can be activated for savings on the patient's copay.  This card doesn't work with Medicaid plans unfortunately.  In order to use this savings card, you have to write the Rx for 6 trays/90 day supply.  This is the most cost effective way to write this Rx for your patient!

4) What to Tell Your Patients

• Restasis is to be used twice a day.  Every day. 
•  It burns when it goes in and this is normal for this drop.
• It may take 3 to 6 months for this drop to reach full effectivity.  Some patients may notice relief as early as 3 weeks.
• Because it takes so long for Restasis to become effective, some doctors will start treatment with a more potent anti-inflammatory such as Lotemax dosed once or twice daily for a month.
• Your pharmacist's directions will tell you to throw the vial away after 1 use.  Do not do this.  Recap your vial after your morning dose and store in a clean environment, then use it again for your night time dose.  This will make the 3 month supply your doctor wrote your Rx for really last 6 months.

Recap your vials to get a full day's use (two drops per eye)