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What wold you tell a patient?

  • 1.  What wold you tell a patient?

    Posted 11-13-2025 12:56
    2 patients were sent to my office in order for me to give my point of view on their GLP-1 treatment as their GP has heard that " GLP-1 treatment might cause blindness..."

    The first patient was a 52 years old male with Diabetes (HgBA1c-8.5) , and deep amlyopia on one eye (VA 20/200 and 20/20 on he other eye)

    The second patient was a 63 years od woman with Diabetes (HgBA1c-7,6),  with hypertension and obesity. Here also one eye has poor visiom due to severe trauma as a child.

    What would you tell these patients that have only one good eye and are afraid of the GLP-1 treament?

    Appreciate your thoughts and vies as this is a "hot" topic 

    Iris


  • 2.  RE: What wold you tell a patient?

    Posted 11-13-2025 13:33
    It should be presented as a choice of relative risks.  If the risk of blindness from AION is doubled by GLP-1 treatment, it just means that instead of 1/10,000 it goes to 2/10,000.  But the risk of going blind from HgA1C of over 7 is probably about 1/20.  1/20 is much, much larger than 2/10,000.  So not taking GLP-1 is much riskier than taking it.  A rare event doubled does not rise to the risk of a common event.

    One of the most foolish mistakes that a physician can make is to overreact to an increased risk of a rare disease (often in their world) while ignoring the much more likely risk from a common disease (often not in their world).  This is the fallacy of myopic reasoning.  

    --Alfredo A. Sadun






  • 3.  RE: What wold you tell a patient?

    Posted 11-13-2025 13:35

    Here is what we jointly wrote  with AAO a few months ago




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  • 4.  RE: What wold you tell a patient?

    Posted 11-13-2025 13:49
    Thank you for reminding us of the importance of diabetic control as a NA-AION risk factor.

    Please weigh in on one possibly important nuance - we have an understanding of the risk of NA-AION in diabetes and the estimated increase risk of diabetics on a GLP-1 RA.   Is the risk of a second NA-AION for a diabetic on a GLP-1 RA the same as it was before the first one?  

    Thanks so much!

    Stu



    Stuart E. Sinoff, M.D.
    Swedish Neuro-Ophthalmology, Seattle








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  • 5.  RE: What wold you tell a patient?

    Posted 11-14-2025 09:18
    We do not yet have data to assess that risk.




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  • 6.  RE: What wold you tell a patient?

    Posted 11-16-2025 19:42
    Right.  But the situation that we are seeing in clinic is the patient who already has a unilateral NA-AION and are taking a GLP-1 or are about to start one.  

    Describing the risk for that patient as 2/10,000, which reflects the increased risk of a first NA-AION on a GLP receptor agonist - maybe, but until we know that risk, it feels different.   And how many of our diabetics have other vascular risk factors?   Type II DM often is accompanied by both hyperlipidemia and hypertension.  A good number of them awakened with their painless visual loss and have severe OSA as well.  Further, the seeing eye may now have a very crowded disc.   We don't know the risk, but it does not seem fair to tell that patient that their risk of the second eye is 2/10,000.   The quoted numbers are appropriate currently for the patient on a GLP-1 who has not had an event.

    Stu



    Stuart E. Sinoff, M.D.
    Swedish Neuro-Ophthalmology, Seattle








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  • 7.  RE: What wold you tell a patient?

    Posted 11-16-2025 21:20
    It!s not. We know if you have an attack in one eye , second eye involvement is 15-50%, so doubling the the risk then should make it an absolute contradiction, I would think 



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  • 8.  RE: What wold you tell a patient?

    Posted 11-16-2025 21:23
    I agree completely Stu. You would tell any patient with a unilateral NAION that they have an approximately 30% chance or so of developing fellow eye visual loss over the upcoming decade. It would certainly be misleading to tell them that continuation of a GLP1 agonist would be any less than that from the data we have thus far.
    Matt


    Sent via the Samsung Galaxy S21 5G, an AT&T 5G smartphone




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  • 9.  RE: What wold you tell a patient?

    Posted 11-17-2025 12:46
    In fact, Matt, I presume you should tell them the medication will likely double that risk 





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  • 10.  RE: What wold you tell a patient?

    Posted 11-17-2025 18:23
    We just don't know that yet (although you may well be right), but I would certainly never tell them it would be any less than the known natural history... Of course, we may find some surprises when we have more data in this regard. 

    Matt


    Sent via the Samsung Galaxy S21 5G, an AT&T 5G smartphone




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  • 11.  RE: What wold you tell a patient?

    Posted 11-13-2025 14:17

    2/10000 is 1/5000, sounds like a significant  risk for an irreversible vision loss

    1/20 (the risk of going blind with HbA1c >7)is high ,but

    is it the only drug that can keep HbA1c below 7?

    If semaglutide is irreplaceable in the treatment regime then saving vision has always been secondary to saving life. By all means has to be used.

    But if there are other options to keep the HbA1c under control and the patient has precious little vision then it can be avoided, especially in those with a small crowded disc and diabetic retinopathy 

    It's also been evaluated for its effect on the diabetic retinopathy , which has been suspected to worsen with treatment.



    ------------------------------
    Shikha
    ------------------------------

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  • 12.  RE: What wold you tell a patient?

    Posted 11-13-2025 14:49
    Did you also take into consideration that:
    1)  NAION is unilateral 85% of the time; whereas diabetic retinopathy is usually bilateral?
    2)  Vision loss isn't the only threat to uncontrolled diabetics.  These patients, aged 50-60 with such high HgA1c are ticking time bombs that will explode in 10-20 years.
    3)  Yes, there are other medications but they ALL have undesirable side effects that produce more frequent complications than 1/5,000.  

    You make the good point that if we see a higher risk of NAION (fellow eye already lost, or at least a severe disc at risk), then the odds shift and we need to reconsider. That's the Bayesian analysis of medicine.  
    But I want to be the gadfly that reminds as many people as possible that we tend to emotionally discount broader considerations when the medical problems land on other physician's doorsteps.  Too many specialists are too focused on protecting only their organ system.  

    Thanks for the soap box.

    Alfredo




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  • 13.  RE: What wold you tell a patient?

    Posted 11-13-2025 21:16
    I like and agree with your soapbox speech.

    I’ll add the obvious thing that one has to document that risk options were presented to the patient, and the patient decides.

    Having said that, the GLP-1s I feel are going to continue to prove themselves extremely beneficial for longevity. Not just heart disease, stroke, peripheral vascular disease, but also joints, self esteem, probably much more we don’t know yet…. Including the possibility that the overall risk of NA-AION is less with GLP-1s!

    Mitch


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  • 14.  RE: What wold you tell a patient?

    Posted 11-16-2025 15:36
    Understand when you say 2/10,000 it is vs 1/10000 doing nothing. And if you think 1/10,000 is a significant risk, do you discuss post-cataract ischemic optic neuropathy with your cataract patients, at 1/1000?
    Though personally if someone asked me about the medication, I would explain the risk 




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