Demonstrate the Value of Omega-3s

Frank Bucci, MD; Sheri Rowen, MD; and Alice Epitropoulos, MD, join Marguerite McDonald, MD, to discuss omega-3 fatty acids and their effect on dry eye disease. Dr. Bucci explains how this nutraceutical can change the composition of a patient's meibum, and Dr. Epitropoulos describes a recently published article demonstrating that oral consumption of omega-3 fatty acids leads to improvement in tear osmolarity. Dr. Rowen highlights the ideal amount of supplementation a patient needs to alleviate dry eye symptoms.

MARGUERITE: Welcome to another edition of the Informed Consent: Getting to Yes podcast—where top ophthalmologists talk about their treatment approach and tell us how the words they use with patients get them to accept their recommendations, while still covering the pros and cons. I’m your host, Marguerite McDonald of the Ophthalmic Consultants of Long Island, in Lynbrook, New York. Today’s topic is Omega 3. Each of our guests will tell us why they believe in it and how they communicate its value to their patients.

MARGUERITE: With us today are Dr. Frank Bucci, medical director of Bucci Laser Vision Institute in Wilkes-Barre, Pennsylvania.

FRANK: My pleasure. Nice to be with you.

MARGUERITE: Dr. Sheri Rowen, medical director of NVISION Eye Centers in Newport Beach, California is also here.

SHERI: Thank you, Marguerite.

MARGUERITE: And finally, we’re pleased to have Dr. Alice Epitropoulos, founding partner of the Eye Center of Columbus and clinical assistant professor in the Department of Ophthalmology at Ohio State University. I’m anxious to hear each of your thoughts on how omega 3 helps alleviate dry eye, and how you use it in your practices.

ALICE: Thank you, Marguerite, thank you for having me.

MARGUERITE: Frank, you're an expert on many, many things, one of which is omega 3. Tell us a little about your background, your history with omega 3, how you got interested, what your thoughts are about the best formulations.

FRANK: When I started I think almost 10 years ago, when the principals of PRN, Physician Recommended Nutriceuticals, came to me and said they had this nutraceutical that could change the composition of the meibum in your meibomian glands. It would significantly improve dry eye. I actually didn't really believe it in the beginning, and then I saw some data and talked with them and started actually using it as a supplement. I had almost, something like, 10 years of experience.

Along the way, done more research and looked at the literature, and really anecdotally, it kind of overwhelms you how well your patients do. Especially at this little sidelight, especially with something like LipiFlow, where you open the gland up, and now you have this better quality, meibomian secretion coming out and how it's helped gain success with those demanding refractive surgery patients, both LASIK and implants.

SHERI: /// I actually have been interested in nutritional products for a very long time, since medical school.

MARGUERITE: This is Sheri Rowen.

SHERI: I've always researched what we could do to supplement our health with supplements. Now that I became an ophthalmologist, I started concentrating more on what we would need to do for eye health. As I was doing research and trying to deal with the problems of dry eye, I came across literature about omega 3 way back in the mid 2000s, and ran into some people from PRN Omega 3 who basically educated me about the triglyceride form of omega 3, versus what we might get in most of the other places.

ALICE: We published an article in September’s issue of Cornea demonstrating that oral consumption of re-esterified omega 3 fatty acids experienced a statistically significant improvement in tear osmolarity, symptom scores, improvement in the quality of tear film as evidenced by an improved tear breakup time, along with increased omega 3 index levels. And then we also noticed a reduction in MMP9 positivity.

MARGUERITE: Well this landmark paper from September, 2016, in Cornea, has garnered a lot of positive attention from around the world and the effect of the omega 3s showed up very quickly, didn’t it?

ALICE: It did. We noticed an improvement in the omega 3 index levels from baseline at 12 weeks. We also noticed an improvement in tear osmolarity as early as 6 weeks, and symptom scores improved a little bit after our objective signs improved at 12 weeks. And, you know, I think that we see that often, that we notice an improvement in objective signs of dry eye, whether it be tear osmolarity or MMP9 prior to patients actually feeling better.

So I think this helps with compliance, you know, that if patients see that their numbers are improving, even though they might not be feeling better, they’re likely to continue that therapy.

MARGUERITE: I totally agree. When you find someone who is for a cataract evaluation and you’ve empowered your techs to show you the data or bring you in early when they detect that there is significant dry eye, do you cut off the exam, put them on treatment, bring them back later and say we’re going to finish the rest of your evaluation when your eye is healthy, and if so, how long do they have to be on treatment including omega 3s before you bring them back?

ALICE: Well I typically complete my exam, I, you know, get some baseline measurements, topography and biometry and I do their full dilated exam, go over informed consent, and again, I have a discussion, if they are dry then I will put them on treatment, usually an immunomodulator and an omega 3, and if they have significant Meibomian gland dysfunction, then I will recommend a LipiFlow thermal pulsation treatment, and then bring them back after about a month to repeat their measurements.

MARGUERITE: I think Dr. Bucci wants to comment on your study in Cornea.

FRANK: Having seen the data through the years and seeing the anecdotal data, and now being followed by last year's publication in Cornea, when that particular formulation at 3 to 1 EPA to DHA formulation, which is now patented. And a multicenter study had significantly improved outcomes in dry eye—five different outcomes. So that was kind of the crowning jewel on what many of us knew was happening. ///

MARGUERITE: /// So, tell us about the 3 to 1 formulation and how they arrived at the conclusion that that was the best ratio.

FRANK: Well, it's 3:1 EPA to DHA, so three EPA to one DHA. And as you know, we've always been with Restasis and various other formulations and knowing how even steroids can temporarily help dry eye, that there is a strong inflammatory component to dry eye, so it kind of made sense since EPA is the ingredient in omegas that is specifically antiinflammatory, and I like to say that DHA is kind of like a neurological support. And that's another little sidelight why omegas also help against macular degeneration has a lot to do with that DHA in there also.

No one knew what the magic formula was, but the 3:1 was based on the idea that there's a strong component of inflammation as the etiology of actually both kinds of dry eye. Both aqueous dry eye and evaporative, meibomian gland dry eye, there is a significant inflammatory component.

MARGUERITE: And the various formulas differ somewhat in bioavailability, isn't that correct?

FRANK: That's the key distinction. This is a part of my getting to yes with patients. I try to show and tell them this very quickly because they got the point, and they all heard that omegas are good for you. Then they say, "Why? There's 25 omegas over at the drugstore," and I tell them, "24 out of 25 are going to stink, all the ethyl ester omega 3." Then I tell them, "Let me just give you the quick, real true story."

Over in Norway, the fish are squeezing to get the oil all out, and the whole world's contaminated with PCPs and mercury, and no one can digest that oil, so what do they have to do? They process it, and it’s process in an alcohol distillation. What happens, that original molecule which is glycerol with three fatty acids, that what's makes it omega 3, and gives you all the health benefits and it lowers cholesterol, and lowers triglyceride, and helps joint pain. So when you do the alcohol distillation, this molecule called ethanol comes in and replaces the glycerol. Now, it's not a natural molecule, but if you go to the biochemistry book, it still says it's an omega. It's an ethyl ester omega. The companies not wanting to spend the money to do this thing called — I tell them it's a big word — re-esterification, I said, "All that means is you kick the ethynol out and put the glycerol back." I said, "That's what PRN does."

They do that, and now they're back to the original molecule, it's purified, and it's concentrated. I said, "It's not magic why this works and the others don't. It's because it will be bioabsorbed much better, 3:1 to 5:1 in various studies. It'll reach blood levels and get to target tissues, and make the good things happen. That's why your dry eye gets better, and why you can prevent macular degeneration, and why the cholesterol goes down, and why the triglycerides were there, and why your joint pain is better.”

Sometimes, I can go into a little bit more detail, I can slow down and fill in a little more information depending on their education level, and how much they can absorb. They're a sponge looking for information. You dish it out, and you can see whether they're absorbing it and understanding it.

So, you know that encouraging patients and giving them a reason to do something increases compliance.

MARGUERITE: Sheri, how do you quickly explain to a patient why you want them on a specific formulation? If they say, "Oh, I'm already on it, doc. I just get whatever's on sale." How do you impart the importance of a specific formulation in a way that they can understand?

SHERI: It's interesting, because everybody who is on omega 3 will say exactly that. "I'm already on it." Then I'll say, "Well, how many milligrams are you taking? What's your EPA and DHA dose? Is it a triglyceride form?" They have no idea. Then I say, "Well, literature has shown that we require a certain amount of supplementation to achieve the end point." I'll cite the multicenter trial where this omega 3 from PRN was actually, with the triglyceride form, was actually studied and shown to be the only one to date that has been in a multicenter trial, to prove that it improves the OSDI. That's the symptomatic index for a patient, their tear form breakup time, their vision. Their MMP9 goes down. There's a lot of things that it does. Patients say, "Oh, okay, so now it's evidence based." They can go right, they'll just actually switch for me.

MARGUERITE: What if they say, "Oh, doc, I eat fish a lot. Two meals a day I eat fish." How do you answer that one?

SHERI: Well, sometimes, believe it or not, they do get a lot of omega 3. In fact, I eat a lot of fish myself. I tested myself. There is a test you can do for your patients to see if they're complying with what you want them to do. It's called Omega Quant. You can find out how much omega 3 is in their system. When I did mine it was pretty high just from the fish. So I supplemented a little. Maybe I'll say, "Well, you might only need two a day instead of four a day." We can utilize that to help monitor what they take, how much they need, and we can know what their progress is.

We can also try a few extra a day and see if their symptoms improve. Then we can say, "This is probably a better way for you to have more of what you need, what the specific EPA/DHA combo you need available for your dry eyes."

I start out with four capsules a day. That seems to have helped me achieve what I want for most of my patients. Some patients come in, as you say, eat tons of fish. They might only need two a day. Some people have a hard time tolerating omega 3, so maybe we'll try two a day for them, one in the morning, one at night, or maybe just two. Sometimes we just need to get a little bit in. I was astounded with how many people actually showed improvement in their symptoms by going on just that, even for the first six weeks.

MARGUERITE: What do you say when they comment, "But doctor, I get fish burps when I take omega 3s?"

FRANK: I said, "This new kind, this kind I'm talking about is pure triglyceride. It's gone through re-esterification. The product that I'm showing you, it doesn't give you the fish burps where the ethanol, the ethyl ester gives you the fish burps but because of the ethanol, not because of the fish oil."

I said, "The last time you had a big swordfish dinner or salmon dinner, did you start burping and belching?" They go, "No," and I said, "See? The fish oil doesn't make you burp and belch. It's this ethanol." They'll try to use tricks like making a thick coating or put it in a refrigerator first, and all that does is prevent it from digesting at the proper place anyway. That will reduce bioavailability even more.

I said, "This is a natural form. It's a natural molecule. Mother nature made your body knowing you were going to eat fish. It accepts this molecule, and it will increase the absorption into your blood system.

MARGUERITE: I’d like to know whether you tell patients to split the dosage, or can they take all the omega 3 pills at the same time?

FRANK: I say, "The classic is two at breakfast, two at dinner, but I don't want you to think if you missed your two in the morning, you can't take more than two at night." And I then tell them, "You know, this stuff's so good. I just want you to get four a day in with food. You wanna take four with a big breakfast, fine. Four with a big dinner, fine. You wanna do one, one, two, that's fine. Just get it in there. Stuff's so great."

SHERI: I've done it both ways. We first started out splitting it. Then some people came in and said, "Well, I take four at once." I said, "You don't have any problem?" They go, "No, it's fine." A lot of people just want to get their dosage over with, because they don't remember. A lot of people can do things in the morning, and they forget to take things at night. In the morning they have a routine. If they can get all four in, they'll take all four. If not, they'll do the two, and two later.

MARGUERITE: Well, this has been a fascinating discussion. Does anyone have anything else to add?

FRANK: There's always a cost issue with a certain percentage of patients, so I try to break it down where I'll say, "There's 25 ethyl ester companies, and there's three of this pure triglyceride. There's Nordic Naturals which is maybe $68 a bottle on average for 120, and Icelandic is $63 a bottle for 120, and PRN's about $44 for 120."

So I say, "Here, you're getting the really superior product and that's what, $1.18 a day?" I think I say, "Pill for pill, dollar for dollar. The preventive medicine involved in beside what it's going to do for your dry eye, prevent macular degeneration, it's worth it." Again, you want them to be compliant. You want them to feel like they're getting their money's worth.

MARGUERITE: And I think we have certainly gotten our money’s worth today. Thanks to all of you.

FRANK: Great. Thanks a lot, Marguerite.

SHERI: Thank you for having me.

ALICE: Thank you so much, I appreciate the invitation.

MARGUERITE: You’re all welcome. And thanks for listening. Remember to keep an eye out for the next edition of the Informed Consent: Getting to Yes podcast.