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Cosmos Study - Collaboration

Liraglutide and Insulin Prescriptions Associated with Increased Likelihood of Rare Vision Loss 

September 10, 2024
Dual-Team Study
Team A:Kersten Bartelt, RNSwarup Swaminathan, MDBrendan Joyce
Team B:Steve Allen, MDJoe Deckert, PhD

Key Findings

  • Patients with type 2 diabetes who are prescribed liraglutide have a 179% higher likelihood of developing non-arteritic anterior ischemic optic neuropathy (NAION), while those prescribed insulin have an 86% greater likelihood compared to patients who were prescribed other diabetes medications. No significant association was found between semaglutide or dulaglutide and NAION. 
  • Overall, NAION is rare, affecting only three per 100,000 patients with diabetes. 

Non-arteritic anterior ischemic optic neuropathy (NAION) is a rare but serious condition that causes sudden, acute, and painless vision loss due to reduced blood flow to the optic nerve. NAION is most common among patients with diabetes, hypertension, hyperlipidemia, or sleep apnea.1 GLP-1 medications are widely used for the treatment of type 2 diabetes and, more recently, weight loss. However, there have been some concerns about the potential adverse effects of GLP-1s, including NAION.2 

We aimed to understand the relationship between GLP-1 medications and the likelihood of NAION among patients with type 2 diabetes. We studied 2,446,482 patients with diabetes who were prescribed a diabetes management medication or a GLP-1 for at least 90 days continuously. We compared the patients prescribed a GLP-1 medication with those who were prescribed insulin or other diabetes medications and no history of GLP-1 usage. We adjusted for patient age, sex, BMI, HbA1c, smoking status, and history of cardiovascular disease, chronic kidney disease, hyperlipidemia, hypertension, sleep apnea, and PDE5 inhibitor use.  

We found that patients who were prescribed liraglutide had a 179% greater likelihood of being diagnosed with NAION than patients prescribed other diabetes medications, while those prescribed insulin had an 86% greater likelihood, as seen in Figure 1. No statistically significant association was found between semaglutide or dulaglutide and NAION.

Figure 1
Likelihood of NAION by Diabetes Medication
Likelihood of NAION by Diabetes Medication
Figure 1. The likelihood of a diabetic patient being diagnosed with NAION by medication.

Despite the increased likelihood of NAION with liraglutide and insulin, it remains a rare condition. Only three per 100,000 patients with diabetes in the study were diagnosed with NAION. As such, the confidence intervals for each treatment studied are wide, and the exact impact on the likelihood of NAION is hard to estimate. Furthermore, the increased likelihood of NAION among patients treated with insulin suggests that differences in diabetes progression or control may also affect likelihood of NAION. 

These data come from Cosmos, a dataset created in collaboration with a community of Epic health systems representing more than 270 million patient records from 1,500 hospitals and more than 35,500 clinics from all 50 states, Lebanon, and Saudi Arabia. This study was completed by two teams that worked independently, each composed of a clinician and research scientists. The two teams came to similar conclusions. Graphics by Brian Olson. 

References

  1. NAION: Diagnosis and Management. American Academy of Ophthalmology. Published August 1, 2022. https://www.aao.org/eyenet/article/naion-diagnosis-and-management. Accessed August 12, 2024. 
  2. Hathaway JT, Shah MP, Hathaway DB, et al. Risk of nonarteritic anterior ischemic optic neuropathy in patients prescribed semaglutide. JAMA Ophthalmol. Published online 2024. doi:10.1001/jamaophthalmol.2024.2296