When do you use GLP-1 receptor agonists for the management of patients with idiopathic intracranial hypertension (IIH)?

I would use GLP-1 agonists in all overweight IIH patients who did not have a contraindication if it wasn't for the cost. In the IIH treatment trial, 6% weight loss over 6 months lowered intracranial pressure by about 50 mm (acetazolamide also lowered ICP by about 50 mm, but of course, it did it much faster). Also, it has been shown in most patients that the more the weight loss, the more the decrease in ICP. And there is evidence that GLP-1 agonists may lower ICP. There are two ways to get insurance to cover GLP-1 agonists in IIH patients: 1) treat any type 2 diabetes or prediabetes, and 2) treat the often associated sleep apnea. Hopefully, this treatment will someday be approved for IIH.

There is good data that these medications not only lead to weight loss, a key part of IIH resolution, but also may reduce ICP directly. We, as physicians, should advocate for our patients to have access to these medications, even if they are expensive or otherwise limited in terms of usage.

IIH is a potentially blinding disease and a significant percentage of patients lose nerve fibers or have permanent VF loss. Acetazolamide mitigates the optic nerve swelling, but it does not address the problem or 'put the patient into remission'. Weight loss has that ability. GLP-1's are not a silver bullet and are not without their side effects and problems, but are simpler than gastric banding or other alternatives and reversible by stopping the medicine.