Talk:Pilocarpine

Typically we have the lead follow the order of the body. Thus "mechanism" goes after side effects.

The text "whilst concurrently reducing uveoscleral drainage"

Why is reducing bolded? We do not just bold stuff because we want to emphasize it. Also the page "uveoscleral drainage" does not exist and likely should not.

Also the bare url to the book need more details such as a page number.

This medication is also used by mouth. Doc James (talk · contribs · email) 09:55, 5 May 2018 (UTC)

You have reverted my last edit even though my summary explained that I would include the reference details in the subsequent version. You're engaging in blatant edit-warring and you're preventing me from even making the changes that we can both easily agree on. Vitreology (talk) 10:10, 5 May 2018 (UTC)

I disagree with your changes.

This is a better summary "Pilocarpine is a medication used to treat increased pressure inside the eye and dry mouth."

Than this "Pilocarpine is a cholinergic medication which is primarily applied topically to the the eye."

Your addition was without a reference (previous content had a reference)

Additionally the medication is used by mouth to treat dry mouth. Not sure why that was removed from the first sentence by you.Doc James (talk · contribs · email) 10:19, 5 May 2018 (UTC)

You're allowed to disagree with my changes. You're not allowed to revert just because you disagree. My addition did have a reference ^[1], I'm not sure what you're talking about. If you weren't blocking me from editing via an edit war I would indicate that it is page 76 of this book. Whilst oral pilocarpine is a route of administration for isolated conditions (eg Sjorens), it is not the most historically significant or important route, thus it should be mentioned further down the article.

But we don't have to agree on some or all of this. But you're not allowed to just revert my edits because you disagree with me. Vitreology (talk) 10:46, 5 May 2018 (UTC)

What about BRD? Anyway have the book.

It does not mention pilocarpine on that page.

It does say "Cholinergic-induced ciliary muscle constriction reduces the spaces between the ciliary muscle fibers and reduces uveoscleral outflow"

Not a great ref for the topic in question as it does not mention the med in question.

The ref that book uses for the statement in question is this https://www.ncbi.nlm.nih.gov/pubmed/?term=19920539

Regardless the effect off pilocarpine on decreasing uveoscleral drainage is much less than the increase in drainage via the trabecular meshwork.

These details do not belong in the second sentence and do not need to be bolded. This is a minor thing that can go in the body of the article if at all. Doc James (talk · contribs · email) 11:08, 5 May 2018 (UTC)

• This is so dull. Well done, you've just cited the inline citation from my original citation - a primary source from 25 years ago. Well done. Alternatively, you could try this text from 2011 (p291) ^[2], or this review from 2017 ^[3]. Vitreology (talk) 14:38, 5 May 2018 (UTC)

I read on another wiki page that this is an antidote to deadly nightshade poisoning. I am not a chemist so hopefully someone can edit the wiki page. — Preceding unsigned comment added by 67.169.2.92 (talk) 05:33, 6 March 2022 (UTC) @Doc James::

Are you going to respond to the point I've raised and/or undo the revert of the lead you did?

If we reach an impasse I will be escalating this, to avoid an edit war. Vitreology talk 00:44, 19 September 2019 (UTC)

Is there anything specifically in the lead, other than the references, that you object to? Vitreology talk 00:50, 19 September 2019 (UTC)

Give Doc James a break. There is WP:NODEADLINE on Wikipedia. Doc has a pretty wild and busy schedule, so it can sometimes take a day to get back to you. But he is usually pretty fast. Let him get back to you and discuss it. I came here from a WP:3O request, which I have declined for now, as the issue has not been discussed sufficiently. If you discuss the issue and still are at an impasse, feel free to relist the debate at 3O and we'll take a second look. Captain Eek ^{Edits Ho Cap'n!}⚓ 01:36, 19 September 2019 (UTC)

@CaptainEek: Thank you for responding to the WP:3O request. Vitreology talk 02:52, 19 September 2019 (UTC)

The ref says "Pilocarpine is no longer routinely used for long term IOP control due to a poor side effect profile"

This better supports "However, due to it's side effects it is no longer typically used in the long term management of increased pressure in the eye."

Than "However, due to it's side effects it is no longer typically used in the long term management of the most common cause of glaucoma, primary open angle glaucoma."

Doc James (talk · contribs · email) 23:46, 18 September 2019 (UTC)

@Doc James:: You are mistaken. "Long term IOP control" means it is treating a chronic condition. The most common chronic form of the disease glaucoma is primary open angle glaucoma. Please restore the original version. Thank you, Vitreology talk 23:59, 18 September 2019 (UTC)

Ocular hypertension is more than just glaucoma. This wording is better supported by what the sources say. Doc James (talk · contribs · email) 00:02, 19 September 2019 (UTC)

Again, I'm really sorry, but that is also completely incorrect. Ocular hypertension is by definition a condition which does not require treatment. It is only once ocular hypertension manifests as evidence of nerve fibre layer thinning which corresponds with a visual field change, that 'ocular hypertension' takes on the name glaucoma. Ophthalmologists treat glaucoma; they monitor ocular hypertension. Hope that helps. Vitreology talk 00:14, 19 September 2019 (UTC)

User:Vitreology Are you saying this is completely incorrect? "However, due to it's side effects it is no longer typically used in the long term management of increased pressure in the eye" Doc James (talk · contribs · email) 03:23, 19 September 2019 (UTC)

No. That quote is correct. I am saying this is incorrect: "Ocular hypertension is more than just glaucoma." Once again, "ocular hypertension" does NOT require treatment. This article a medical treatment. The term "ocular hypertension" should be completely removed from this article. Vitreology talk 05:40, 19 September 2019 (UTC)

You just tagged this sentence but you are saying it is correct? "However, due to it's side effects it is no longer typically used in the long term management of increased pressure in the eye." Doc James (talk · contribs · email) 05:51, 19 September 2019 (UTC)

Sorry I was in the process of clarifying what I meant, but led to an edit clash, so rather than modify what I wrote above, I'll insert it below:

User:Vitreology Are you saying this is completely incorrect? "However, due to it's side effects it is no longer typically used in the long term management of increased pressure in the eye" Doc James (talk · contribs · email) 03:23, 19 September 2019 (UTC)

That quote is dubious only because of the use of the phrase "increased pressure in the eye". I originally had the phrase as "However, due to it's side effects it is no longer typrically used in the long term management of primary open angle glaucoma. As you'll see from my explaination of normal tension glaucoma in ref2: In the most common type of glaucoma (primary open angle glaucoma), the eye pressure on any particular day is not what is important. What is important, and what guides treatment, is whether there are signs of damage from glaucoma. When there are signs of damage from glaucoma, you aim to reduce the eye pressure, regardless of whether the eye pressure was 'within' or 'above' the normal range of 10-21 to begin with.

For ocular hypertension and "increased eye pressure" I am making precisely the same point. You do not treat either of them. You treat glaucoma - a diagnosis which does not require an eye pressure measurement. Vitreology talk 06:00, 19 September 2019 (UTC)

Source states "Pilocarpine is no longer routinely used for long term IOP control due to a poor side effect profile" Per this ocular hypertension is often treated. This source by the AAO also makes it clear that increased intraocular pressure / ocular hypertension is sometimes treated. Doc James (talk · contribs · email) 06:07, 19 September 2019 (UTC)

This is not supported by the refs provided

"Pilocarpine is a medication used to make the pupil of the eye smaller, the pressure inside the eye lower, and to increase the saliva in the mouth.^[1] As eye drops, it is predominantly used to temporarily manage angle closure glaucoma until surgery can be performed, and when a doctor needs to reduce the size of the pupil as an adjunct to surgical management of abnormally high eye pressure (glaucoma)."

This is

"Pilocarpine is a medication used to treat increased pressure inside the eye and dry mouth.^[2] As eye drops it is used temporarily manage angle closure glaucoma until surgery can be performed, ocular hypertension, open angle glaucoma, and to bring about constriction of the pupil following its dilation.^[2][3]"

So restored that supported by the refs Doc James (talk · contribs · email) 23:48, 18 September 2019 (UTC)

The primary issue here is actual lead, not the references. The comparison you have made here is using two different references for the same incorrect lead. Please restore the lead in this revision ^[4], ie:

Pilocarpine is a medication used to make the pupil of the eye smaller, the pressure inside the eye lower, and to increase the saliva in the mouth.^[1] As eye drops, it is predominantly used to temporarily manage angle closure glaucoma until surgery can be performed, and when a doctor needs to reduce the size of the pupil as an adjunct to surgical management of abnormally high eye pressure (glaucoma). However, due to it's side effects it is no longer typically used in the long term management of the most common cause of glaucoma, primary open angle glaucoma.

and I will be happy to work with you to choose the most appropriate references to support the lead. Vitreology talk 00:08, 19 September 2019 (UTC)

This ref is fairly clear on the uses for lowering IOP.

• ::: Look at the date of the references in that link ^[5]

The second ref discusses its use to treat dry mouth.

Not sure why the refs were removed from the second bit? Doc James (talk · contribs · email) 03:39, 19 September 2019 (UTC)

The second ref says "Uses: chronic open-angle glaucoma, ocular hypertension; emergency treatment of acute angle-closure glaucoma; to antagonize effects of mydriasis and cycloplegia following surgery or ophthalmoscopic examination." Not sure why this was removed? Doc James (talk · contribs · email) 03:42, 19 September 2019 (UTC)

• :::: I don't recall removing that reference. However, the WHO document is from 2008. A lot has changed since then.

My #1 issue with the lead is that it:

1. Doesn't emphisise that Pilo's current use is generally only as a "one-off" application, to prepare the eye for a surgical procedure (in angle closure glaucoma, pilocarpine is used to prepare the eye for peripheral iridotomy, and to prevent pupil block while a patient is being prepared for emergency cataract extraction. It is simply NOT used for long term medical management of eye conditions (except in extremely isolated and specific situations, which are far too nuanced to be worthwhile including in the article)
2. As mentioned in Refs1, Ocular hypertension describes a slight elevation in intraocular pressure which has not manifested with clinical signs of glaucoma, and therefore, does not require treatment. The 'normal' range of intraocular pressure is 10-21. A large proportion of the population (especially those with slightly increased corneal thickness) can have an eye pressure of 23 for their entire life with absolutely no harm whatsoever. These people have "Ocular hypertension", because their eye pressure is high, but nothing needs to be done about it (treat the patient, not the number). On the other hand, there are many people who have an eye pressure of 12 or 13 (at the lower end of the normal range) and experience severe progression of their glaucoma - and you're raising hell to get their pressure down from 13 to 10, trying to prevent them from going blind before you see them in a week's time --> these people have normal eye pressure, but are becoming blind from glaucoma --> This is known as Normal_tension_glaucoma

• • As you can see, whether the 'eye pressure' is increased, decreased or normal, means absolutely nothing at all. Furthermore, when patients with Normal_tension_glaucoma read an articles like Pilocarpine, (which contain misleading remarks about the significance of 'eye pressure'), it materially reduces their compliance with the glaucoma medication ophthalmologists prescribe for them

"But Wikipedia said these eye drops are for people with increased eye pressure. But my eye pressure is normal. So, I don't think I need to use them"

• • • Every instance of Ocular hypertension, as well as all unqualified references to increased eye pressure which do not disambiguate ocular hypertension from glaucoma, need to be urgently removed.

Cheers, Vitreology talk 05:34, 19 September 2019 (UTC)

This source also mentioned ocular hypertension as a use "This medication is used alone or with other medications to treat high pressure inside the eye due to glaucoma or other eye diseases (e.g., ocular hypertension)." as does the monograph at the FDA. Doc James (talk · contribs · email) 06:02, 19 September 2019 (UTC)

The source is wrong. Vitreology talk 06:06, 19 September 2019 (UTC)

I would strongly recommend using using AAO (American Academy of Ophthalmology) whereever possible, eg: ^[1]. The AAO are the most reliable and broadly trusted ophthalmic source across most parts of the world. Vitreology talk 06:12, 19 September 2019 (UTC)

We have a lot of sources that discuss the treatment of ocular hypertension.

The AAO is a suitable source and discusses treatment here and it discusses the use of medications. One does not wait until vision loss has occurred (ie glaucoma) to start treatment. "However, your ophthalmologist may decide that you need medicine to lower your intraocular pressure. Eyedrop medicine can lower eye pressure." Doc James (talk · contribs · email) 06:17, 19 September 2019 (UTC)

Again, for ocular hypertension, they are closely monitored. Sometimes they reach a diagnosis of glaucoma, sometimes you follow ocular hypertension patients for years and years and they have absolutely no signs of glaucoma, so you see them less frequently (or follow up with an optometrist, for instance). Often patients with "ocular hypertension" are referred to as "glaucoma suspects". This means they fulfil some the diagnostic criteria of glaucoma, but not enough to be given a diagnosis of glaucoma.

To bring this back to the issue of whether pilocarpine is used for ongoing management of glaucoma, please see this link ^[2]. Vitreology talk 06:29, 19 September 2019 (UTC)

This is the variation in practice "Some ophthalmologists treat all elevated intraocular pressures of higher than 21 mm Hg with topical medicines. Some do not medically treat unless there is evidence of optic nerve damage. Most ophthalmologists treat if pressures are consistently higher than 28-30 mm Hg because of the high risk of optic nerve damage."

There is no consensus on whether to treat ocular hypertension (aka Glaucoma suspects) or not. It is a case by case decision, based on an estimate of whether the patient will progress to develop glaucoma within their lifetime. Thus, would be less likely to treat a patient aged over 90yo with ocular hypertension, as compared with a 50yo with ocular hypertension. As such, if you 'insist' in including such a 'grey zone' in the lead of this article, I would also insist that the word sometimes precedes the phrase ocular hypertension. If, someday, the clinical practice guidelines change so that they recommend that "everyone with an intraocular pressure higher than 21mmHg receives treatment", I will then change my position on this. Vitreology talk 08:57, 19 September 2019 (UTC)

This is an excellent overview of the topic: Vitreology talk 08:57, 19 September 2019 (UTC)

Pilocarpine is still extensively used in the developing world for glaucoma as it is inexpensive.Doc James (talk · contribs · email) 06:48, 19 September 2019 (UTC)

That may be true, but this is now unconventional and not the recommended management. Aloe Vera is also cheap. However, just as the lead for the article Aloe Vera has not claimed that it is a treatment for cataract, ocular discharge and itchy eyes (even though some parts of the world use it for this , so too should the lead for Pilocarpine not claim that it is a treatment for the "ongoing" management of glaucoma. As I previously said, it is mainly used as a 'one-off' application, to help prepare the eye for surgical management shortly thereafter. Vitreology talk 08:57, 19 September 2019 (UTC)

The World Health Organization lists it for this use. Doc James (talk · contribs · email) 00:06, 20 September 2019 (UTC)

(just had to split this up, it's getting quite lengthy) Vitreology talk 08:57, 19 September 2019 (UTC)

Okay found a source specifically on this: "Ocular hypertension If initial treatment with a topical prostaglandin analogue is not tolerated, an alternative prostaglandin analogue should be tried before switching to a topical beta-blocker such as betaxolol, levobunolol hydrochloride, or timolol maleate). If treatment is still not tolerated, alternative options include carbonic anhydrase inhibitors such as brinzolamide or dorzolamide, a topical sympathomimetic such as apraclonidine or brimonidine tartrate, or a topical miotic such as pilocarpine, given either as monotherapy or as combination therapy." Doc James (talk · contribs · email) 07:11, 19 September 2019 (UTC)

Unfortunately, users are unable to access that link, unless they are within the UK.

But lets run with the quote as you've written:

"Ocular hypertension If (first line) initial treatment with a topical prostaglandin analogue is not tolerated, an (second line) alternative prostaglandin analogue should be tried before switching to a (third line) topical beta-blocker such as betaxolol, levobunolol hydrochloride, or timolol maleate). If treatment is still not tolerated, alternative options include (fourth line) carbonic anhydrase inhibitors such as brinzolamide or dorzolamide, a topical sympathomimetic such as apraclonidine or brimonidine tartrate, or a topical miotic such as pilocarpine, given either as monotherapy or as combination therapy."

Sure no one claims it is first line in the developed world where money is not an option / all options are avaliable. It is however an option for ocular hypertension and used more often in the developing world. Doc James (talk · contribs · email) 00:02, 20 September 2019 (UTC)

1. There is no consensus for whether clinicians treat ocular hypertension or simply monitor for progression towards glaucoma
2. Treating ocular hypertension is only cost effective in patients younger than 65.
3. Far fewer clinicians treat "low-range" ocular hypertension (eg 21-24) than (28-30+) because the latter group has a far higher probability of progressing to glaucoma.
4. A tiny proportion of the population have intraocular pressure within (28-30+) range to begin with.
5. Pilocarpine has not been a first line therapy for the ongoing management of glaucoma since 1978.
6. Pilocarpine is now considered a "fourth-line" agent, (if treatment of ocular hypertension is even necessary in the first place).

With all this, the relevance of 'ocular hypertension' to the drug Pilocarpine is plain to see. I think the majority of community would agree that in an article about Pilocarpine, any reference to ocular hypertension should nothing more than a footnote, at the very most. Vitreology talk 08:57, 19 September 2019 (UTC)

It is approved for use in ocular hypertension. It is listed as an essential medicine by the World Health Organization for this use. It is an inexpensive option for this purpose. Not everything on Wikipedia needs to be exclusively geared towards the Western world. Doc James (talk · contribs · email) 00:04, 20 September 2019 (UTC)

Include Ocular Hypertension in the article, but remove it from the lead. Vitreology talk 02:26, 20 September 2019 (UTC)