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Nitric Oxide-donating Prostaglandin Analogue — Glaucoma Pregnancy: Avoid — prostaglandins affect uterine tone; NO donors also carry theoretical risk

Latanoprostene Bunod 0.024% Eye Drops

Brand names: Vyzulta

Adult dose

Dose: 1 drop once daily in the evening
Route: Topical (ophthalmic)
Frequency: Once daily at bedtime
Max: 1 drop once daily
Dual mechanism: metabolised to latanoprost acid (prostaglandin F2α analogue — increases uveoscleral outflow) AND butanediol mononitrate (releases nitric oxide — increases trabecular meshwork outflow via guanylyl cyclase/cGMP/PKG pathway). Complements both outflow pathways.

Paediatric dose

Route:
Not licensed for paediatric use — seek specialist opinion

Dose adjustments

Renal

No adjustment — topical use

Hepatic

No adjustment

Clinical pearls

  • APOLLO and LUNAR trials: latanoprostene bunod 0.024% demonstrated superior IOP reduction compared to timolol 0.5% BD (–9.0 mmHg vs –7.8 mmHg) — adding nitric oxide-mediated trabecular outflow to uveoscleral prostaglandin outflow provides additive IOP reduction
  • Dual outflow mechanism: latanoprost acid targets uveoscleral (unconventional) outflow via FP receptors; released nitric oxide targets trabecular (conventional) outflow via cGMP/PKG-mediated relaxation of trabecular meshwork cells — complementary to netarsudil (pure ROCK/trabecular mechanism)
  • Compared to latanoprost: latanoprostene bunod provides approximately 1–2 mmHg additional IOP reduction compared to latanoprost alone in head-to-head studies — the nitric oxide component provides this incremental benefit
  • Prostaglandin periorbitopathy class effect: same PAP risk as other prostaglandin analogues — inform patients about irreversible iris darkening, periocular skin pigmentation, eyelash changes, and deepening upper lid sulcus
  • Not yet routinely available in all UK formularies — check local NHS formulary availability; may require specialist initiation

Contraindications

  • Hypersensitivity to latanoprostene bunod or latanoprost
  • Active intraocular inflammation (uveitis — CME risk)
  • Narrow angle glaucoma without iridotomy

Side effects

  • Conjunctival hyperaemia — common (class prostaglandin effect)
  • Iris colour change (heterochromia) — irreversible
  • Prostaglandin-associated periorbitopathy (PAP) — deepening sulcus, enophthalmos, ptosis
  • Eyelash hypertrichosis and periocular pigmentation
  • Stinging and burning
  • Headache

Interactions

  • Other prostaglandin analogues — do not combine; no additive benefit, increased side effects
  • NSAIDs — may reduce prostaglandin analogue IOP-lowering efficacy

Monitoring

  • IOP at 4–8 weeks after initiation
  • Iris colour (baseline photography)
  • Periocular skin and eyelid changes
  • Ocular surface

Reference: BNFc; BNF 90; APOLLO Trial (Am J Ophthalmol 2016); LUNAR Trial (Am J Ophthalmol 2016); EGS Glaucoma Guidelines 2020; SPC Vyzulta. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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