What are the recommendations for a patient with well-controlled type 2 diabetes (T2D) and controlled blood pressure, taking a Glucagon-like peptide-1 (GLP-1) receptor agonist?

From the Guidelines

For a patient with well-controlled type 2 diabetes, controlled blood pressure, and diabetic retinopathy who is taking a GLP-1 receptor agonist, I strongly recommend annual comprehensive dilated eye examinations by an ophthalmologist or optometrist experienced in diabetic eye care, as emphasized by the latest guidelines 1. This approach is crucial for early detection and management of any progression of retinopathy. The patient should continue with their current GLP-1 agonist therapy, as it aids in glycemic control and may provide cardiovascular benefits, in line with recommendations from recent studies 1. Key aspects of management include:

• Maintaining tight glycemic control with a target HbA1c below 7%, as highlighted in the 2025 standards of care for diabetes 1.
• Continuing good blood pressure management with a target of less than 130/80 mmHg, which is essential for reducing the risk of diabetic retinopathy progression 1.
• If retinopathy is moderate to severe, considering treatments like laser photocoagulation, anti-VEGF injections (such as ranibizumab, aflibercept, or bevacizumab), or vitrectomy as recommended by an eye specialist, based on the severity of the retinopathy and the patient's overall health status. Regular monitoring of kidney function is also vital, given the frequent coexistence of diabetic nephropathy with retinopathy 1. Lifestyle modifications, including smoking cessation, regular physical activity, and a balanced diet, are foundational to diabetes management and can help slow retinopathy progression by improving overall vascular health, as supported by general principles of diabetes care 1.

From the FDA Drug Label

• Diabetic Retinopathy Complications: Has been reported in a clinical trial. Patients with a history of diabetic retinopathy should be monitored (5.3). The patient with well-controlled type 2 diabetes and controlled blood pressure, taking a GLP-1 receptor agonist like semaglutide, should be monitored for diabetic retinopathy complications, as it has been reported in clinical trials 2.

• Key points:
  • Patients with a history of diabetic retinopathy should be monitored.
  • The medication may increase the risk of diabetic retinopathy complications.

From the Research

Recommendations for Retinopathy in Well-Controlled Type 2 Diabetes

• For patients with well-controlled type 2 diabetes and controlled blood pressure, taking a GLP-1 receptor agonist, the current evidence suggests that these medications may have a neutral or potentially worsening effect on diabetic retinopathy 3, 4.
• A study published in 2017 found that GLP-1R agonists had beneficial effects on cardiovascular outcomes, but their results regarding the progression of diabetic retinopathy were neutral or worse compared to placebo 3.
• Another study published in 2022 found that GLP-1RA was associated with an elevated risk of rapidly worsening diabetic retinopathy in patients with type 2 diabetes 4.
• However, a study published in 2018 found that use of GLP-1 RAs was not associated with an increased risk of incident diabetic retinopathy compared to current use of two or more oral antidiabetic drugs, and was associated with a decreased risk of diabetic retinopathy compared to insulin 5.
• It is essential to note that the evidence is not consistent, and more research is needed to fully understand the effects of GLP-1 receptor agonists on diabetic retinopathy.

Blood Pressure Control and Diabetic Retinopathy

• A study published in 2003 found that intensified control of blood glucose and blood pressure prevented diabetic retinopathy in randomized controlled trials, but the prevalence of proliferative diabetic retinopathy remained unchanged 6.
• The study suggested that earlier diagnosis and more aggressive control of blood glucose and blood pressure decreased the duration-adjusted prevalence of background diabetic retinopathy, but not of sight-threatening proliferative retinopathy 6.

GLP-1 Receptor Agonists and Cardiovascular Outcomes

• A systematic review and meta-analysis published in 2025 found that long-acting GLP-1RA reduced the incidence of major adverse cardiovascular events, hospitalization for heart failure, and all-cause mortality in patients with type 2 diabetes 7.
• The review found no significant heterogeneity by GLP-1RA administration route (subcutaneous vs. oral) and no increased risks of severe hypoglycemia, retinopathy, or pancreatic events 7.