“Risk of Nonarteritic Anterior Ischemic Optic Neuropathy in Patients Prescribed Semaglutide“

• This study from July, 2024, is the first to find that patients who were prescribed semaglutide were more likely to develop an irreversible blindness secondary to nonarteritic anterior ischemic optic neuropathy (NAION).
• Patients with diabetes who were prescribed semaglutide were more than four times more likely to be diagnosed with NAION. 
• Patients who were overweight or obese and prescribed semaglutide were more than seven times more likely to be diagnosed with NAION. 
• The study was observational, and more research is needed to confirm a direct causal link between semaglutide and NAION.

Identifying Data:

50YOM, D.E.

Date & Time of Encounter: 9/15/24 2:15pm

Chief Complaint: LUQ pain x 2 days

History of Present Illness:

50YOM with PMH of HTN and obesity, currently taking semaglutide for weight loss (last dose 4 days ago); presents for evaluation of LUQ pain and nausea x 2 days. Pt reports intermittent, sharp pain that he ranks 5/10 in severity “just below his ribs” on the left, non-radiating. The pain began suddenly ~1 day after his last dose of semaglutide (.5mg) and occurs at least 5x a day in episodes that last about 3 minutes each. Episodes seem to be unprovoked but are slightly alleviated by positioning, specifically hunching himself forward. It is accompanied by nausea, but he denies vomiting. Reports diminished appetite, last oral intake was a piece of toast this morning. Reports bowel and bladder function consistent with his baseline. Denies fever, diarrhea, constipation, back pain, dysuria. Denies h/o previous abdominal surgeries. Denies CP, SOB, DOE.

Pt has been on weekly semaglutide for ~6 weeks, during which he has not received any follow-up medical care from the prescriber; He is unfamiliar with any one individual who is his prescriber as he receives the prescription from an large online service. His dose was increased from .25mg to .5mg ~2 weeks ago. Reports ~12lb weight loss since beginning treatment. He denies h/o symptoms similar to this after previous injections. He denies h/o pancreatitis or biliary tree pathologies, denies h/o personal thyroid pathology including cancer, denies h/o retinopathies but states he has never seen an ophthalmologist. Reports that his sister survived thyroid cancer (unknown type) at age 43. 

History

Past Medical History:

Present chronic illnesses – 

1. Hypertension
2. Obesity

Past medical illnesses – Denies past illnesses

Childhood illnesses – Denies childhood illnesses

Immunizations – Up to date, including COVID-19. 

Screening tests and results – Up to date

Past Surgical History:

Denies

Medications:

1. Valsartan 320mg
2. Amlodipine 10mg
3. Semaglutide .25mg

Vitamins and Supplement 

Denies

Allergies:

NKDA

Denies food and environmental allergies.

Family History:

Father – Deceased, CHF, CAD, DMT2, HTN

Mother – Alive, HLD

Sister – Alive, h/o thyroid cancer at age 43, now in remission

Social History:

D.E. is married and lives with his wife and two children.

He is a school teacher.

Reports social alcohol intake, 1-2 drinks/week

He denies smoking cigarettes/cigars, or using illicit drugs. Denies ever smoking.

He reports drinking 2 cups of coffee/day.

He denies recent travel.

He reports he eats a well-balanced diet, only rarely eating take-out or desserts.

He reports a mostly sedentary lifestyle, but says he tries to take daily walks.

He reports getting 6-7 hours of sleep each night. 

He is sexually active with his wife only.

Review of Systems:

General – Reports weight loss since beginning semaglutide. Denies fever, fatigue.

Skin, hair, nails – Denies new vascular changes, color changes, rashes, or lesions.

Head – Denies dizziness, syncope, or head trauma.

Eyes – Denies changes in vision, discharge, or injection.

Ears – Denies changes in hearing, pain, or discharge.

Nose/sinuses – Denies nasal congestion, sinus congestion, or sinus tenderness.

Mouth/throat – Denies sore throat, difficulty swallowing, or voice changes. 

Neck – Denies swelling, tenderness, or stiffness.

Pulmonary system – Denies cough, pleuritic pain, or dyspnea.

Cardiovascular system –  Denies CP, DOE, palpitations.

Gastrointestinal system – Reports LUQ pain, nausea, and diminished appetite. Denies vomiting, diarrhea, or blood in stool.

Genitourinary system – Denies urinary frequency or urgency, dysuria, or flank pain.

Nervous – Denies weakness, ataxia, paresthesias, or loss of strength from baseline. 

Musculoskeletal system – Denies pain, tenderness, or abnormal range of motion from baseline.

Peripheral vascular system –  Denies varicose veins, peripheral ulcerations, or cold extremities.

Endocrine system – Denies heat or cold intolerance, excessive sweating, or excessive thirst.

Psychiatric – Denies anxious or depressive mood, denies h/o psychological or psychiatric care.

Physical

Vital Signs: 

Wt: 320 lbs

Ht: 70”

BMI: 45.9

Temp: 98.4F, surface

Pulse: 84 bpm, regular rate and rhythm 

Resp: 18 rpm, unlabored

Sp02: 99% on room air

BP: 132/82 Sitting R arm           

General: 

Well-nourished, neatly groomed white male, A&Ox4, that looks younger than his stated age, dressed appropriately for the weather. Pt appears slightly uncomfortable sitting in the exam chair.

Skin, Hair and Nails:

Skin is warm & moist, good turgor. Nonicteric, no lesions noted, no scars. No visible tattoos or markings.

Hair is average quantity and distribution. 

Eyes:

Symmetrical OU. No strabismus, exophthalmos or ptosis.  Sclera white, cornea clear, conjunctiva pink.

Nose:

Symmetrical with no masses, lesions, deformities, or trauma. Nares patent bilaterally. 

Neck:

Trachea midline. No masses, lesions, scars, or visible pulsations noted. No palpable cervical adenopathy. Thyroid non-tender, no thyromegaly, no palpable nodules noted.

Lungs:

CTA B/L, no adventitious breath sounds

Heart:

Carotid pulses are 2+ bilaterally without bruit. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4.  No splitting of S2 or friction rubs appreciated.

Abdomen:

Epigastrum and LUQ tender to deep palpation, no guarding or rebound noted. Epigastrium appears slightly distended. Abdomen is otherwise non-tender, flat, and symmetric. No scars, striae or pulsations noted.  Bowel sounds normoactive in all four quadrants. No hepatosplenomegaly or CVA tenderness. Murphy’s sign negative, Rovsing’s sign negative. 

Neuro

Symmetric muscle bulk with good tone of upper and lower extremities. Non-antalgic, symmetrical gait.

Assessment:

50YOM with PMH of HTN and obesity, currently taking weekly semaglutide for weight loss from outside facility with minimal medical supervision. He presents with 2 days of episodic sharp LUQ pain which began ~1 day after his last semaglutide injection, requiring further work-up.

Notable problem list differentials: LUQ Pain

1. Semaglutide-induced pancreatitis
   1. Acute pancreatitis/cholelithiasis is a known adverse effect associated with semaglutide.
2. Gallstone pancreatitis
   1. Aside from semaglutide use, this patient has many pre-existing risk factors for cholelithiasis, which is the most common cause of acute pancreatitis.
3. Bowel Obstruction
   1. Semaglutide slows GI processes, which can result in constipation and other issues. This patient denies changes to bowel habits, but it’s important to keep in mind.
4. Diverticulitis
   1. Left-sided pain with nausea can be a presentation of diverticulitis, but without change in bowel habits, is less likely. 
5. Gastroenteritis
   1. It’s possible the patient simply ate something that upset his GI tract, resulting in nausea and pain. This seems less likely after 2 days of symptoms without vomiting or diarrhea.

Plan

1. Obesity
2. LUQ Pain
   1. Blood draw in-office
      1. CBC, CMP, amylase, lipase, lipid panel, HbA1C, FT4, TSH
   2. Urine sample provided in office for UA
   3. PT scheduled for in-house RUQ u/s
   4. PT given ER precautions, if pain worsens or persists or if fever develops
   5. HOLD semaglutide, and before resuming:
      1. RTC in 2 days for lab results
      2. Refer to ophtho to establish care
      3. Baseline thyroid U/S
3. HTN
   1. C/w Valsartan 320mg
   2. C/w Amlodipine 10mg

My recent site evaluation with Dr. Alie, alongside my classmates Fionna and Ariel, provided a great opportunity for reflection and discussion on a variety of clinical topics. One of the key aspects of the meeting was our review of medications, particularly the risks and benefits of prescribing analgesics and semaglutide. It was interesting to delve into these discussions, as it broadened my understanding of both pain management and the implications of newer treatments like semaglutide. Presenting patients during the evaluation also highlighted the differences in our rotations—while Fionna and I were in family medicine, Ariel was completing his ambulatory medicine rotation. This diversity in our experiences made the conversation even more enriching, as we could compare and contrast the clinical approaches in each setting. Overall, the session reinforced my understanding of medication management and enhanced my confidence in clinical decision-making, contributing to my growth as a clinician.

My recent family medicine rotation with Dr. Berkowitz was an incredibly enriching experience. Dr. Berkowitz is a knowledgeable internist who has been seeing some of the same patients since the 1980s. He taught me not only about clinical medicine, but also about the art of patient care. His approach to patients—using kindness, humor, and grace, especially when dealing with disgruntled individuals—was something I deeply admired and hope to emulate in my own practice.

One area in which I grew significantly during this rotation was understanding and interpreting labs, which has always been a weakness of mine. Dr. Berkowitz’s extensive knowledge in this area helped me build confidence in reading routine lab results and also knowing when to order more specialized tests. This skill will undoubtedly serve me well in my future practice, as lab interpretation is such a critical component of patient care.

Overall, this rotation not only expanded my clinical knowledge, especially in terms of lab work, but also reinforced the importance of maintaining a compassionate, patient-centered approach to care. Seeing Dr. Berkowitz’s long-standing relationships with his patients highlighted the value of continuity and trust in family medicine, making this rotation both an educational and inspirational experience.