Existing fixed-combination glaucoma products, and those under development, reflect common concomitant usage in clinical practice. With so many new drugs to choose from, the optimal order in which to utilize drug classes in the traditional stepped treatment algorithm is less obvious than ever before. And with emerging evidence that lower and less variable IOP best prevents the progression of glaucoma, the tradition of adding only one drug at a time may no longer be universally applicable.

In an era of many drug choices and the ability to individualize patient care as never before,45 the fixed combinations limit clinicians' ability to customize dosing regimens. Unless prescribed with caution, fixed-combination drugs may result in overtreatment for patients who may be controlled with a single agent or fewer doses of combined medications if dosed concomitantly. Fixed combinations offer advantages over concomitant therapy in terms of reduced cost, increased compliance, and reduction of the washout effect and exposure to preservatives.

In the face of so many choices, the challenge is to keep medical therapy reasonable. The current concept of reasonable medical therapy probably consists of two bottles, one of which is a fixed-combination product.

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