BACKGROUND: Diabetic retinopathy (DR) is a leading cause of acquired vision loss in middle-aged adults. Glucagon-like peptide-1 receptor agonists (GLP-1RA) are widely used in the management of type 2 diabetes (T2D). Emerging evidence has suggested a possible link between GLP-1 RAs and the acceleration of DR. However, the evidence on the association between GLP-1RA therapies and risk for DR has been mixed, and there is limited guidance on how to manage new onset or worsening DR for patients taking GLP-1RA therapy. The objective of this case report is to describe the clinical decision-making involved in the management of a patient with T2D who developed new-onset and worsening retinopathy following the initiation of several GLP-1RA therapies.
CASE SUMMARY: A 43-year-old female with T2D and class II obesity was diagnosed with mild nonproliferative DR after taking various GLP1-RA therapy (ie, exenatide ER and dulaglutide) and maintaining glycemic control for 19 months. The patient was later transitioned to subcutaneous semaglutide for additional weight loss, and diabetic macular edema was detected in the right eye 2 months after. Due to a potentially lower risk of DR complications, treatment was promptly switched to oral semaglutide. The patient's eye exam revealed that her DR improved and diabetic macular edema had significantly resolved 8 months after switching therapy.
PRACTICE IMPLICATIONS: This case highlights a progressive decline in retinal health despite well-controlled T2D and the possible contribution of GLP-1RA therapy to DR progression. Switching to GLP-1RA agents with potentially lower risk for DR, such as oral semaglutide, may be beneficial when patients develop DR on GLP1-RA therapy. Further studies that evaluate the risk of DR while using GLP-1RA therapy, as well as the risk across the GLP1-RA class, are needed. Additional guidance on managing possible new onset or worsening DR on GLP-1RA therapy is especially necessary.