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
Original Message:
Sent: 11/13/2025 2:49:00 PM
From: Alfredo Sadun
Subject: RE: What wold you tell a patient?
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
Original Message:
Sent: 11/13/2025 2:17:00 PM
From: Shikha TALWAR
Subject: RE: What wold you tell a patient?
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.
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Shikha
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Original Message:
Sent: 11-13-2025 13:32
From: Alfredo Sadun
Subject: What wold you tell a patient?
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
Original Message:
Sent: 11/13/2025 12:56:00 PM
From: Iris Krashin Bichler
Subject: What wold you tell a patient?
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