Fixed Combination Glaucoma Treatment — Alpha-2 Agonist + Beta-blocker Pregnancy: SPC §4.6: there are no adequate data for the brimonidine/timolol fixed combination in pregnant women; should not be used during pregnancy unless clearly necessary. If administered in pregnancy up to the time of delivery, the neonate should be carefully monitored during the first days of life (beta-blockade: bradycardia, hypotension, respiratory distress, hypoglycaemia). Should not be used by women breast-feeding infants.

Brimonidine / Timolol Fixed Combination

Brand names: Combigan

This fixed-combination ophthalmic drop pairs brimonidine, a selective alpha-2 adrenergic agonist, with timolol, a non-selective beta-blocker, to lower intraocular pressure in open-angle glaucoma and ocular hypertension inadequately controlled by one agent.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: One drop in the affected eye(s)

Route: Topical ocular (eye drops, solution — brimonidine tartrate 2 mg/ml + timolol 5 mg/ml)

Frequency: Twice daily, approximately 12 hours apart

SPC §4.2 'Recommended dosage in adults (including the elderly)': one drop in the affected eye(s) twice daily, approximately 12 hours apart. No separate elderly dose is given. If more than one topical ophthalmic product is used, instil the different products at least 5 minutes apart. To reduce systemic absorption, compress the lachrymal sac at the medial canthus (punctal occlusion) or close the eyelids for two minutes immediately after each drop. Paediatric: contraindicated in neonates and infants (less than 2 years of age); safety and effectiveness in children and adolescents 2–17 years have not been established, so use is not recommended in children or adolescents. Children 2 years and above, especially 2–7 years and/or weighing ≤20 kg, should be treated with caution and closely monitored due to the high incidence and severity of somnolence (§4.4). No UK SPC §4.5 text was present in the fetched bundle; interactions listed below are taken from §4.3. No US (openFDA) record was fetched for this product.

Dose adjustments

Renal

SPC §4.2: has not been studied in patients with hepatic or renal impairment; caution should be used in treating such patients. No numeric dose adjustment is stated.

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

Hypersensitivity to the active substances or to any of the excipients
Reactive airway disease including bronchial asthma or a history of bronchial asthma; severe chronic obstructive pulmonary disease
Sinus bradycardia, sick sinus syndrome, sino-atrial block, second or third-degree atrioventricular block not controlled with pacemaker; overt cardiac failure; cardiogenic shock
Use in neonates and infants (less than 2 years of age)
Patients receiving monoamine oxidase (MAO) inhibitor therapy
Patients on antidepressants which affect noradrenergic transmission (e.g. tricyclic antidepressants and mianserin)

Side effects

Conjunctival hyperaemia (very common; approximately 15% of patients)
Burning sensation in the eye (very common; approximately 11% of patients)
Stinging sensation in the eye, allergic conjunctivitis, corneal erosion, superficial punctate keratitis, eye pruritus (common)
Somnolence and headache (common)
Oral dryness (common)
Hypertension (common); depression (common)

Interactions

Monoamine oxidase (MAO) inhibitors — contraindicated (SPC §4.3)
Antidepressants affecting noradrenergic transmission, e.g. tricyclic antidepressants and mianserin — contraindicated (SPC §4.3)
Other topical ophthalmic products — instil at least 5 minutes apart (SPC §4.2)

Clinical monograph

How it works

Brimonidine reduces aqueous humour production and enhances uveoscleral outflow via alpha-2 receptor stimulation, while timolol decreases aqueous production through beta-blockade, providing additive pressure lowering.

Prescribing in practice

The timolol component contraindicates use in asthma, bronchospasm, severe COPD and significant bradyarrhythmia or uncontrolled heart failure; warn of systemic beta-blocker effects.
Brimonidine can cause drowsiness, dry mouth and ocular allergic conjunctivitis, and crosses the blood-brain barrier, so it must be avoided in neonates and infants because of the risk of apnoea and CNS depression.
Caution with concurrent CNS depressants, antihypertensives and monoamine oxidase inhibitors, and advise punctal occlusion to limit systemic absorption.

Monitoring

Monitor intraocular pressure, watch for ocular allergic reactions to brimonidine, and check heart rate and respiratory tolerance in susceptible patients.

Counselling the patient

Instil twice daily and press on the inner corner of the eye briefly after each dose.
It may cause tiredness or a dry mouth; take care if driving until you know how it affects you.
Report a red, itchy or sticky eye, which may indicate an allergic reaction.

Evidence & guidelines

NICE and specialist glaucoma practice endorse fixed alpha-2 agonist/beta-blocker combinations as a step-up option to consolidate dosing and improve adherence.

Reference: NICE NG81 (Glaucoma); MHRA Brimonidine Paediatric Safety Warning; SPC Combigan; Confirm identity and dosing against the manufacturer SPC (eMC) and NICE. Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways