Can dulaglutide (glucagon-like peptide-1 receptor agonist) cause vision loss?

Dulaglutide and Vision Loss

Dulaglutide may cause worsening of diabetic retinopathy, particularly in patients with pre-existing proliferative retinopathy, and has been associated with a small risk of other optic nerve disorders. 1, 2

Risk of Retinopathy Complications

• Dulaglutide and other GLP-1 receptor agonists (GLP-1 RAs) have been identified as potentially causing worsening of diabetic retinopathy in patients with pre-existing retinopathy 2, 3
• The American College of Cardiology specifically lists "history of proliferative retinopathy" as a consideration requiring caution when using dulaglutide 1
• The mechanism appears to be related to rapid reduction in blood glucose levels rather than a direct toxic effect of the medication 2, 3
• The risk is most pronounced in patients with:
  • Pre-existing proliferative retinopathy 1, 2
  • Rapid and substantial decreases in HbA1c (>1.0%) 3

Risk Assessment and Comparison

• For the overall GLP-1 RA class, the rate difference for worsening retinopathy is small (number needed to harm = 1000) 3
• For semaglutide specifically, the risk is higher (number needed to harm = 77) 3
• A 2025 comparative effectiveness study found no significant difference in risk of sight-threatening diabetic retinopathy complications between dulaglutide and other GLP-1 RAs (semaglutide, liraglutide, and exenatide) in patients with type 2 diabetes at moderate cardiovascular risk 4

Emerging Evidence on Other Visual Complications

• Recent research has identified an increased risk of non-arteritic anterior ischemic optic neuropathy (NAION) and other optic nerve disorders with GLP-1 RAs 5, 6
• A 2025 cohort study found that patients prescribed semaglutide or tirzepatide had an increased risk of NAION (hazard ratio 1.76) and other optic nerve disorders (hazard ratio 1.65), although the absolute risk remained low 6
• A case report described a patient who developed NAION after four months of semaglutide therapy 5

Recommendations for Management

• Baseline eye examination should be performed before initiating dulaglutide therapy 2
• For patients with type 2 diabetes, an initial dilated eye examination should be conducted at the time of diabetes diagnosis 2
• If no retinopathy is present and glycemia is well controlled, screening every 1-2 years may be considered 2
• If any level of diabetic retinopathy is present:
  • Dilated retinal examinations should be repeated at least annually 2
  • Consider more gradual improvement in glycemic control to minimize the risk of worsening retinopathy 2
  • More frequent monitoring is necessary when starting GLP-1 RAs 2
• If retinopathy is progressing or sight-threatening, more frequent examinations by an ophthalmologist are required 2

Risk-Benefit Considerations

• When prescribing dulaglutide, the cardiovascular benefits (number needed to treat for MACE = 77) should be weighed against the potential risk of retinopathy complications 3
• Close collaboration with ophthalmology is recommended to grade the baseline degree of retinopathy when initiating and following patients on dulaglutide 3
• Optimize blood pressure and serum lipid control to reduce the risk or slow the progression of diabetic retinopathy in patients on dulaglutide 2