BLOG: What would you risk for a miracle?
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What risks should we accept in exchange for a miracle?
GLP-1 receptor agonist drugs for diabetes and obesity have been miracle products for now millions of people around the world. The mechanism of action of these new drugs is to mimic the action of the endogenous GLP-1 hormone, which is secreted in response to food intake. This increases glucose-dependent insulin production, inhibits glucagon release and slows down emptying of the stomach, effectively reducing glucose spikes and promoting satiety.
Thousands of testimonials on the internet celebrate “miraculous” results for poorly controlled diabetes and for patients with morbid obesity who had run out of options. These drugs effectively reduce weight by as much as 20%, for many of our patients “curing” diabetes and hypertension and greatly diminishing the future risk for stroke, heart attack and other consequences of diabetes. As with all drugs, clinical trials showed some concerns and side effects, such as acute pancreatitis, gastrointestinal upset and even an increase in thyroid C cell tumors, which were observed only in animal studies. And most of us have seen patients for whom these drugs did not work so well or were intolerable.
The recent study about an increased risk for nonarteritic anterior ischemic optic neuropathy (NAION) by Hathaway and others at Harvard was a complete surprise, raising a new, ominous risk with these drugs — a potentially blinding (usually in just one eye) “stroke” of the optic nerve head.
Should all patients considering these drugs have a pretreatment ocular evaluation for other risk factors for NAION, such as a crowded optic nerve head? Certainly, most patients taking these drugs already have an elevated risk for NAION because of the diabetes, hypertension, sleep apnea and systemic vascular disease that the GLP-1 agonists are intended to address.
Much debate surrounds the applicability of the Hathaway NAION study to the general population. Certainly, we should thank Dr. Rizzo and his colleagues at Harvard for bringing forward this concern. At the same time, dismissing a transformative class of medications on the basis of one study is clearly out of order. Further studies so far point to a less clear picture about the association between GLP-1 drugs and NAION, so our work is not yet done.
But let’s face it: Every new drug poses potential risks that were missed by an FDA study. Always we should ask the question whether we would be willing to accept some risk of a disease that has the potential to visually impair at least one eye of a patient in exchange for the “miraculous” results that it is more likely to achieve.
There may be a role for eye care professionals to perform pretreatment screening of the optic nerve characteristics among these patients. Certainly, educating patients about possible risks, known and unknown, for a drug that so fundamentally alters metabolism is in everybody’s best interests.
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John A. Hovanesian, MD, FACS, an ophthalmologist specializing in cataract, refractive and corneal surgery at Harvard Eye Associates in Laguna Hills, California, can be reached at drhovanesian@harvardeye.com.
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