Semaglutide or Tirzepatide and Optic Nerve and Visual Pathway Disorders in Type 2 Diabetes

Semaglutide and tirzepatide, the new generation of glucagon-like peptide-1 receptor agonist used to treat type 2 diabetes and obesity, were recently reported to be associated with increased risk of nonarteritic anterior ischemic optic neuropathy (NAION). However, reported associations were inconsistent, and it remains unknown if semaglutide or tirzepatide is associated with other disorders of the optic nerve and visual pathways.

To examine associations of treatment with either semaglutide or tirzepatide with first-time diagnoses of optic nerve and visual pathway disorders in patients with type 2 diabetes.

This cohort study emulated target trials based on a nationwide, population-based database of US patient electronic health records from December 2017 to January 2023. Models were adjusted by propensity score matching. Eligible patients had type 2 diabetes and no prior diagnosis of eye disorders and were prescribed semaglutide, tirzepatide, or other antidiabetic medications.

Prescription of semaglutide or tirzepatide vs other antidiabetic medications (insulins, metformin, dipeptidyl-peptidase-4 inhibitors, sodium-glucose cotransporter-2 inhibitors, sulfonylureas, thiazolidinediones, and other glucagon-like peptide 1 receptor agonists).

First-time diagnoses of NAION and other optic nerve disorders during a 2-year follow-up were examined using Cox proportional hazards and Kaplan-Meier survival analyses.

After propensity score matching among 1 511 637 eligible patients, the study population comprised 159 398 matched patients with type 2 diabetes (mean [SD] age, 56.5 [13.3] years; 83 123 women [52.15%]), including 79 699 patients in the semaglutide or tirzepatide group and 79 699 patients in the comparison group. During the 2-year follow-up, there were 35 patients (0.04%) with NAION in the semaglutide or tirzepatide group and 19 patients (0.02%) with NAION in the matched comparison group (hazard ratio, 1.76 [95% CI, 1.01-3.07]). There were 93 patients (0.12%) with other optic nerve disorders in the semaglutide or tirzepatide group and 54 patients (0.07%) with other optic nerve disorders in the matched comparison group (hazard ratio, 1.65 [95% CI, 1.18-2.31]). No association was found with other disorders of the optic nerve or visual pathways.

In this study of patients with type 2 diabetes who had no prior eye disorders, patients prescribed semaglutide or tirzepatide had an increased risk of NAION and other optic nerve disorders, although the overall risk was low. These findings highlight the need for close monitoring of these conditions.