Drugs List

Therapeutic Indications

Uses

Secondary glaucoma
Treatment of elevated intraocular pressure in ocular hypertension
Treatment of elevated intraocular pressure in open-angle glaucoma

Contraindications

Children under 18 years
Wearing of contact lenses
Asthma
Cardiogenic shock
History of asthma
History of obstructive pulmonary disease
Non-paced sinus node dysfunction
Second degree atrioventricular block
Severe chronic obstructive pulmonary disease
Sinoatrial exit block
Sinus bradycardia
Third degree atrioventricular block
Uncontrolled cardiac failure

Precautions and Warnings

Atopy
History of allergies including anaphylaxis
Breastfeeding
Cardiac failure
Cardiovascular disorder
Chronic obstructive pulmonary disease
Corneal disorder
Diabetes mellitus
Hypertension
Hyperthyroidism
Hypoglycaemia
Hypotension
Ischaemic heart disease
Myasthenia gravis
Narrow angle glaucoma
Pregnancy
Prinzmetal's angina
Severe peripheral circulatory disorder
Uncontrolled phaeochromocytoma

Advise diabetic patients that hypoglycaemic symptoms may be reduced/altered
Anaesthetist should be made aware patient is taking this medication
Control cardiac failure before starting treatment
May mask symptoms of hyperthyroidism
May unmask the symptoms of myasthenia gravis
Advise ability to drive/operate machinery may be affected by side effects
Contains benzododecinium bromide
In combined therapy, administer eye products at least 10 minutes apart
To reduce systemic absorption compress lacrimal sac during administration
Assess intra-ocular pressure about 4 weeks after starting treatment
Monitor patient with history of severe cardiac disease for signs of failure
Monitor pulse rates in patients with potential for cardiac failure
Beta blockers may reduce the response to adrenaline in anaphylaxis
Seek doctor's advice if intercurrent ocular condition develops
Systemic absorption & adverse effects of systemic beta blockers may occur
Do not withdraw this drug suddenly
Possibly withdraw treatment if dry eyes and/or skin rash occur
Advise patient to avoid touching the eye/other surfaces with container tip

Pregnancy and Lactation

Pregnancy

Use timolol eye drops with caution in pregnancy.

Studies involving the systemic use of beta blockers did not indicate malformative effects, but some pharmacological effects such as bradycardia have been observed in foetuses and neonates. Systemic use of some beta-blockers can cause intra-uterine growth retardation (IUGR) and reduced placental weight. The use of timolol eye drops during pregnancy has been reported to cause foetal bradycardia.

If, after careful consideration of the risks involved, timolol eye drops are used during pregnancy, it is advisable to consider lacrimal sac compression and removal of any excess on the skin with a tissue.

Any infant, exposed in utero to timolol eye drops should be monitored closely after birth for bradycardia and other symptoms.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Use timolol gel-forming eye drops with caution in breastfeeding.

Timolol is excreted into breast milk. Both oral and ophthalmic drops produce modest levels in milk. In one case report, a woman with elevated intraocular pressure applied ophthalmic 0.5% timolol drops to one eye twice daily, resulting in excretion of the drug in her breast milk. Most authorities consider that the levels seen were below the daily dose that would be below that expected to produce cardiac effects in the infant.

If, after careful consideration of the risks involved, timolol eye drops are used during breastfeeding, it is advisable to consider lacrimal sac compression and removal of any excess on the skin with a tissue.

Infants exposed to timolol via breast milk should be closely observed for hypotension, weakness, hypoglycaemia, sedation, depression, bradycardia and other signs or symptoms of beta blockade.

The manufacturer notes that a decision should be made whether to stop treatment whilst breastfeeding or cease breastfeeding and continue with treatment.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Alopecia
Anaphylaxis
Angina pectoris
Angioedema
Arrhythmias
Arthralgia
Arthropathy
Asthenia
Blepharitis
Blurred vision (transient)
Bradycardia
Bronchospasm
Burning and stinging of the eyes
Cardiac arrest
Cerebral ischaemia
Cerebrovascular accident
Chest pain
Choroidal detachment (following filtration surgery)
Claudication
Cold extremities
Confusion
Congestive cardiac failure
Conjunctivitis
Cough
Decreased corneal sensitivity
Decreased exercise tolerance
Depression
Diarrhoea
Difficulty in micturition
Diplopia
Dizziness
Dry mouth
Dryness and irritation of eyes
Dyspepsia
Dyspnoea
Exacerbation of psoriasis
Exfoliative dermatitis
Extremity pain
Fatigue
Gastralgia
Hallucinations
Headache
Heart block
Hyperglycaemia
Hypersensitivity reactions
Hypoglycaemia
Hypotension
Impaired concentration
Impotence
Increase in antinuclear antibodies (ANA)
Increased dreaming
Insomnia
Keratitis
Loss of libido
Memory loss
Myasthenia gravis-like syndrome
Nasal congestion
Nausea
Nightmares
Non-thrombocytopenic purpura
Ocular discharge
Ocular itching
Oedema
Palpitations
Paraesthesia
Peyronie's disease
Pruritus
Psoriasiform rash
Ptosis
Pulmonary oedema
Rales
Rash
Raynaud's phenomenon
Refractive changes
Respiratory failure
Second and third degree AV block
Sexual dysfunction
Sino-atrial block
Sweating
Syncope
Systemic lupus erythematosus
Tinnitus
Urticaria
Vasodilatation
Vertigo
Visual disturbances
Vomiting
Weakness
Worsening of arterial insufficiency

Presentation

Gel-forming eye drop solution containing timolol (as timolol maleate).

Drugs List

Therapeutic Indications

Uses

Secondary glaucoma
Treatment of elevated intraocular pressure in ocular hypertension
Treatment of elevated intraocular pressure in open-angle glaucoma

Dosage

Adults

Children

Contraindications

Children under 18 years
Wearing of contact lenses
Asthma
Cardiogenic shock
History of asthma
History of obstructive pulmonary disease
Non-paced sinus node dysfunction
Second degree atrioventricular block
Severe chronic obstructive pulmonary disease
Sinoatrial exit block
Sinus bradycardia
Third degree atrioventricular block
Uncontrolled cardiac failure

Precautions and Warnings

Atopy
History of allergies including anaphylaxis
Breastfeeding
Cardiac failure
Cardiovascular disorder
Chronic obstructive pulmonary disease
Corneal disorder
Diabetes mellitus
Hypertension
Hyperthyroidism
Hypoglycaemia
Hypotension
Ischaemic heart disease
Myasthenia gravis
Narrow angle glaucoma
Pregnancy
Prinzmetal's angina
Severe peripheral circulatory disorder
Uncontrolled phaeochromocytoma

Advise diabetic patients that hypoglycaemic symptoms may be reduced/altered
Anaesthetist should be made aware patient is taking this medication
Control cardiac failure before starting treatment
May mask symptoms of hyperthyroidism
May unmask the symptoms of myasthenia gravis
Advise ability to drive/operate machinery may be affected by side effects
Contains benzododecinium bromide
In combined therapy, administer eye products at least 10 minutes apart
To reduce systemic absorption compress lacrimal sac during administration
Assess intra-ocular pressure about 4 weeks after starting treatment
Monitor patient with history of severe cardiac disease for signs of failure
Monitor pulse rates in patients with potential for cardiac failure
Beta blockers may reduce the response to adrenaline in anaphylaxis
Seek doctor's advice if intercurrent ocular condition develops
Systemic absorption & adverse effects of systemic beta blockers may occur
Do not withdraw this drug suddenly
Possibly withdraw treatment if dry eyes and/or skin rash occur
Advise patient to avoid touching the eye/other surfaces with container tip

Pregnancy and Lactation

Pregnancy

Use timolol eye drops with caution in pregnancy.

Studies involving the systemic use of beta blockers did not indicate malformative effects, but some pharmacological effects such as bradycardia have been observed in foetuses and neonates. Systemic use of some beta-blockers can cause intra-uterine growth retardation (IUGR) and reduced placental weight. The use of timolol eye drops during pregnancy has been reported to cause foetal bradycardia.

If, after careful consideration of the risks involved, timolol eye drops are used during pregnancy, it is advisable to consider lacrimal sac compression and removal of any excess on the skin with a tissue.

Any infant, exposed in utero to timolol eye drops should be monitored closely after birth for bradycardia and other symptoms.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Use timolol gel-forming eye drops with caution in breastfeeding.

Timolol is excreted into breast milk. Both oral and ophthalmic drops produce modest levels in milk. In one case report, a woman with elevated intraocular pressure applied ophthalmic 0.5% timolol drops to one eye twice daily, resulting in excretion of the drug in her breast milk. Most authorities consider that the levels seen were below the daily dose that would be below that expected to produce cardiac effects in the infant.

If, after careful consideration of the risks involved, timolol eye drops are used during breastfeeding, it is advisable to consider lacrimal sac compression and removal of any excess on the skin with a tissue.

Infants exposed to timolol via breast milk should be closely observed for hypotension, weakness, hypoglycaemia, sedation, depression, bradycardia and other signs or symptoms of beta blockade.

The manufacturer notes that a decision should be made whether to stop treatment whilst breastfeeding or cease breastfeeding and continue with treatment.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Alopecia
Anaphylaxis
Angina pectoris
Angioedema
Arrhythmias
Arthralgia
Arthropathy
Asthenia
Blepharitis
Blurred vision (transient)
Bradycardia
Bronchospasm
Burning and stinging of the eyes
Cardiac arrest
Cerebral ischaemia
Cerebrovascular accident
Chest pain
Choroidal detachment (following filtration surgery)
Claudication
Cold extremities
Confusion
Congestive cardiac failure
Conjunctivitis
Cough
Decreased corneal sensitivity
Decreased exercise tolerance
Depression
Diarrhoea
Difficulty in micturition
Diplopia
Dizziness
Dry mouth
Dryness and irritation of eyes
Dyspepsia
Dyspnoea
Exacerbation of psoriasis
Exfoliative dermatitis
Extremity pain
Fatigue
Gastralgia
Hallucinations
Headache
Heart block
Hyperglycaemia
Hypersensitivity reactions
Hypoglycaemia
Hypotension
Impaired concentration
Impotence
Increase in antinuclear antibodies (ANA)
Increased dreaming
Insomnia
Keratitis
Loss of libido
Memory loss
Myasthenia gravis-like syndrome
Nasal congestion
Nausea
Nightmares
Non-thrombocytopenic purpura
Ocular discharge
Ocular itching
Oedema
Palpitations
Paraesthesia
Peyronie's disease
Pruritus
Psoriasiform rash
Ptosis
Pulmonary oedema
Rales
Rash
Raynaud's phenomenon
Refractive changes
Respiratory failure
Second and third degree AV block
Sexual dysfunction
Sino-atrial block
Sweating
Syncope
Systemic lupus erythematosus
Tinnitus
Urticaria
Vasodilatation
Vertigo
Visual disturbances
Vomiting
Weakness
Worsening of arterial insufficiency

Overdosage

It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.

The following number will direct the caller to the relevant local centre (0844) 892 0111

Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Further Information

Last Full Review Date: July 2017.

Reference Sources

Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 10th edition (2015) ed. Briggs, G., Freeman, R. Wolters Kluwer Health, Philadelphia.

Medications and Mothers' Milk, Sixteenth Edition (2014) Hale, T and Rowe, H, Hale Publishing, Plano, Texas.

Summary of Product Characteristics: Timoptol LA 0.25% and 0.5% w/v Gel-Forming Eye Drops Solution. Santen UK Limited. July 2015.

US National Library of Medicine. Toxicology Data Network. Drugs and Lactation Database (LactMed).
Available at: https://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
Timolol Last revised: 10 March 2015
Last accessed: 06 July 2017

NICE Evidence Services Available at: www.nice.org.uk Last accessed: 06 July 2017