Early worsening of diabetic retinopathy due to intensive glycaemic control

Abstract

The prevalence of diabetes and diabetic retinopathy is increasing around the world. Glycaemic control is important in reducing the long‐term risk of complications of diabetes, however intensive glycaemic control, particularly in patients with longstanding and poorly controlled diabetes, is associated with the risk of early worsening of diabetic retinopathy and vision loss. We present two clinical cases to illustrate the presentation of early worsening and to highlight a role for intravitreal anti‐vascular endothelial growth factor therapies in ameliorating this phenomenon, as well as a review of the current understanding of this phenomenon. We emphasise the importance of identifying individuals at risk of early worsening of diabetic retinopathy and recommend regular ophthalmological review during the period of intensive glycaemic control to ensure optimal visual outcomes.

Glucagon-Like Peptide 1 Receptor Agonists – Potential Game Changers in the Treatment of Glaucoma?

“…Sterling et al (2021) linked the exposure to GLP-1R agonists ( i.e., dulaglutide, liraglutide, lixisenatide, exenatide , and semaglutide ) to a low risk of developing open-angle glaucoma ( Sterling et al, 2021 ). However, previous studies have raised concern that treatment with GLP-1R agonists may increase the risk of diabetic retinopathy, making them less favorable to be used against diabetic eye complications ( Diabetes Control and Complications Trial Research Group, Nathan et al, 1993 ; No authors listed, 1998 , 1999 ; Aiello and Dcct/Edic Research Group, 2014 ; Green et al, 2015 ; Marso et al, 2016b ; Jingi et al, 2017 ; Tang et al, 2018 ; Bain et al, 2019 ; Lim et al, 2019 ; Bethel et al, 2021 ). Nevertheless, this effect of GLP-1R agonists is most likely caused by a rapid decrease in patients’ blood glucose levels as discussed later ( Vilsbøll et al, 2018 ; Bain et al, 2019 ; Lim et al, 2019 ).…”

“…Thus, several clinical studies have linked the use of DPP4-inhibitors to either a reduced odds of diabetic retinopathy or a reduced risk of diabetic retinopathy progression (Ott et al, 2014;Kim et al, 2018;Wang et al, 2018;Chung et al, 2019;Fan et al, 2020). Nathan et al, 1993;No authors listed, 1998No authors listed, , 1999Aiello and Dcct/Edic Research Group, 2014;Green et al, 2015;Marso et al, 2016b;Jingi et al, 2017;Tang et al, 2018;Bain et al, 2019;Lim et al, 2019;Bethel et al, 2021).…”

“…Nevertheless, this effect of GLP-1R agonists is most likely caused by a rapid decrease in patients' blood glucose levels as discussed later (Vilsbøll et al, 2018;Bain et al, 2019;Lim et al, 2019).…”

Stellungnahme der DOG, der RG und des BVA zur Therapie des diabetischen Makulaödems

“…Außerdem überwiegt der positive Effekt auf die Retinopathie bei Fortsetzung der verbesserten Blutzuckereinstellung. Gerade angesichts der Verfügbarkeit wirksamer Therapien des diabetischen Makulaödems können die Therapieziele der Blutzuckerregulation heutzutage meist unabhängig von induzierten retinalen Veränderungen verfolgt werden [55] [71,72]. Die ophthalmologische Untersuchung des vorderen und des hinteren Augenabschnitts wird zwar in den Fachinformationen der gegen ein diabetisches Makulaödem intravitreal verabreichbaren Medikamente nicht ausdrücklich erwähnt [73,74].…”

Reviewing the reviews

“…Khoo et al 4 conducted a systematic review of pharmaceutical intervention studies for meibomian gland dysfunction, including oral omega‐3 and omega‐6 essential fatty acids, azithromycin, minocycline and doxycycline, plus topical azithromycin, dexamethasone/tobramycin and cyclosporine. Lim et al 5 discussed management of the ‘early worsening’ phenomenon in diabetic retinopathy, using clinical cases to illustrate this difficult situation. Wu et al 6 described the diagnostic and therapeutic approach to viral retinitis, with special mention of systemic immunomodulatory therapy as a risk factor for the condition.…”