Clinical Scorecard: Diabetic Retinopathy and Glucagon-Like Peptide-1 Agonists

At a Glance

Key Highlights

• Dulaglutide and semaglutide strongly associated with worsening diabetic retinopathy; liraglutide and tirzepatide have weaker but significant links; lixisenatide shows no major link.
• GLP-1 agonists improve glycemic control, which may transiently worsen DR similar to insulin therapy effects.
• Frequent DR screening (every 6 to 12 weeks) is recommended for patients on GLP-1 agonists, especially if DR is present or vision loss occurs.

Guideline-Based Recommendations

Diagnosis

• Use assistive technologies such as AI-based screening tools (EyeScreen, iCare ILLUME, LumineticsCore, iPrevent DR) for DR detection and monitoring.
• Employ imaging modalities including B-Scan ultrasonography, fundus photography, OCT-A, spectral-domain OCT, and widefield fluorescein/indocyanine green angiography for detailed retinal assessment.

Management

• Consider prophylactic anti-VEGF injections to reduce DR progression in patients with worsening disease.
• In cases of persistent diabetic macular edema after 3-6 anti-VEGF injections, consider switching to extended treatment anti-VEGF agents, combination anti-VEGF/Ang-2 inhibitors, laser therapy, steroids, or port delivery systems.
• Coordinate with primary care physicians regarding GLP-1/GIP agonist prescriptions in patients with existing DR.

Monitoring & Follow-up

• Shorten follow-up intervals to 6-12 weeks for patients on GLP-1 agonists with DR or vision changes.
• Monitor early visual function changes such as color and contrast sensitivity and electrophysiology abnormalities.
• Consider macular pigment optical density measurements due to carotenoids’ protective effects against DR.

Risks

• GLP-1 agonists, especially semaglutide and dulaglutide, are linked to worsening diabetic retinopathy.
• There is an emerging concern about increased risk of non-arteritic anterior ischemic optic neuropathy (NAION) with semaglutide use.

Patient & Prescribing Data

Patients with type 2 diabetes and obesity using GLP-1 agonists

GLP-1 agonists effectively improve glycemic control and aid weight loss but require careful ocular monitoring due to potential DR progression risks.

Clinical Best Practices

• Maintain close communication between optometrists and primary care physicians regarding GLP-1 agonist use in patients with diabetic retinopathy.
• Implement frequent and comprehensive retinal screening protocols for patients initiating or continuing GLP-1 agonist therapy.
• Utilize advanced imaging and AI technologies to detect early and progressive retinal changes.
• Consider prophylactic and adaptive anti-VEGF treatment strategies to manage DR progression.
• Be vigilant for signs of NAION in patients treated with semaglutide.

References

• FDA Adverse Event Reporting System data analysis on GLP-1 agonists and diabetic retinopathy
• FOCUS Trial on GLP-1 agonists and diabetic eye disease
• JAMA Ophthalmology study on NAION risk with semaglutide