Existing and emerging GLP-1 receptor agonist therapy: Ramifications for diabetic retinopathy screening

Abstract

GLP-1 receptor agonist treatment revolutionised the management of type 2 diabetes mellitus with significant enhancement of cardiovascular risk reduction. They have been instrumental in effectively managing the glycaemic control of this at-risk patient group. This class of drugs are associated with rapid improvement in glucose levels and consequently, transient early worsening of pre-existing diabetic retinopathy (DR) which is well-recognised, but this paradox is less commonly perceived in routine clinical practice. The recent shortage of supply has resulted in an enforced hiatus to prescribing all existing GLP-1 receptor agonists, which is expected to last all through 2024. This becomes even more pertinent as their DR could have progressed due to worsening HbA1c as a result of the unforeseen interruption to GLP-1 receptor agonist treatment. Therefore, when these medications are recommenced in a few months’ time, all prescribers need to be aware of these patients’ most up-to-date DR status and liaise with their affiliated screening service.

Newer treatments for diabetes mellitus: A caveat with rapid glycaemic improvement and caution regarding changes in retinopathy screening guidelines within the UK NHS programme

“…dear editor, Varughese and Jacob highlight the importance of monitoring for early worsening of diabetic retinopathy (DR) on initiation of GLP-1 receptor agonist (GLP-1RA) therapy and the ramifications for retinopathy screening. 1 Pre-existent DR, high HbA1c at initiation, rapid and significant reduction in HbA1c can contribute to this risk. 2,3 Patients with significant DR and maculopathy generally have a personalised retinal management plan and frequent reviews in specialist clinics.…”

“…In this context, as mentioned by Varughese and Jacob, the dual incretin mimetic, tirzepatide may trigger this phenomenon too, given its impact on HbA1c reduction and weight loss; it is pertinent to note that patients with DR were excluded from the tirzepatide trials (SURPASS). 1,5,6 The much-awaited outcome of the Long -term Effects of Semaglutide on Diabetic Retinopathy in subjects with Type 2 diabetes (FOCUS) study will provide useful information. 5 Thus, we reiterate the view that the risk of DR progression should be part of the counselling and consenting process when initiating potent anti-diabetic drugs.…”