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Dr. Koetting: 
This is CE on ReachMD, and I'm Dr. Cecilia Koetting. Here today with me is Douglas Devries, and we're going to talk about a case. So Doug, we've got a patient who's a 66-year-old patient presenting with MGD, irritated eyelids, and we definitely see collarettes. Patient's used tea tree oil but not really found any lasting relief from it. So what are your thoughts on this case?

Dr. Devries: 
Yeah,  that’s a great case, and it's something that happens all the time. And the first thing I'd want to know for the patient is I’d want to look at the meibomian glands. I want to see what type of obstruction there is. There are collarettes on it, so we know there's a Demodex presence on it. But they had been using tea tree oil and they’re disappointed because they found online that that would cure everything.

But I want to know how were they using it, how frequently were they using it, and did they find any improvements whatsoever in this particular case. And the way I would approach it from that, if there's collarettes, if there's MGD, and those meibomian glands are obstructed and thick and turbid, that's not doing any good for the patient whatsoever to lessen the evaporative load, I'm going to start on a therapeutic. I'm going to prescribe lotilaner for this patient and doing that in 6 weeks.

And with the data that was present in both the ERSA and the RHEA data with lotilaner, we saw that it actually increased viable meibomian gland secretions up to 54% I believe was the number.

Dr. Koetting:
Yep, but also in that same study it did back up the phase 3 FDA studies, right, that showed the decrease in mite load as well as collarettes. So not only are you dealing with what we definitely know is the issue, right, the Demodex, but you also, like you said, got an improvement in the meibomian gland function.

Dr. Devries:
And I love it when somebody does that research and it backs up what the original research was. I mean that gives you confidence to say okay this works. And I mean, the numbers were nearly identical. And I think one of the important numbers within those studies showed that that reduction of collarette loads to less than 10 was at 81% in some of the studies. Now that's clinically meaningful to me when I see that kind of reduction.

Dr. Koetting:
Now that it's been out for, we're getting close to 3 years at this point, what are you finding as far as longevity for treatment? What are you seeing longer term outcome wise with lotilaner?

Dr. Devries:
So I think patient education is paramount when you're going to use a therapeutic to make sure they follow the whole course so you can get the full life cycle of the Demodex mite. And what I've seen that when you emphasize that, the patients do so much better. And then I will bring them back at the end of that course to make sure they've been using it, to take a look at the collarettes.

Now, I've had patients that I started treating with lotilaner right when it was released in 2023, and really haven't needed to do another dose. But I have other patients the physiology is such that you can take care of them, you can reduce that collarette load, you can reduce the mite load, and in 4-6 months all of a sudden they're back again.

Dr. Koetting:
And I have those as well where even with at-home cleaning, and I'm going to give them the benefit of the doubt that they're doing it properly, right, but they just need to. And a lot of times those are my pretty heavy duty rosacea patients. I don't know what you've seen.

Dr. Devries:
Oh it's so true. And I think it's a little tougher to tell with you females whether there's rosacea just because you cover it up so well. But the ocular rosacea you're going to see. You're not going to cover that. Now, us guys you walk in the exam room you go—

Dr. Koetting:
I can see you from a mile away. I got it, I got it. Oh you got rosacea. Yes, yes.

Dr. Devries:
So those correlations are so important.

Dr. Koetting:
Yeah, and I think that it sounds like both your and my clinical experience is pretty similar to what was found in the 12-month longevity study of those who had recurrence of collarettes from those who had reached that cure rate which was only about I believe 15% if I'm correct, and that's pretty similar. So.

Dr. Devries:
No, and when you explain to patients this is something that's naturally occurring and this change in physiology that you have can actually promote the growth and along with biofilm and different conditions that you can have and comorbidities that you can have. But I think just emphasizing that patient education and letting them know. And then you got to bring patients back. You got to bring them in and take a look at those patients.

Dr. Koetting:
Absolutely. Well Doug, our time is up. I want to say thank you to you for joining me and then thank our audience for joining us today.

Dr. Devries:
Well thank you, Cecilia.

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