BACKGROUND: Idiopathic intracranial hypertension (IIH) is commonly linked to obesity. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) and bariatric surgery may improve outcomes beyond conventional therapy, but comparative evidence is limited.
METHODS: We systematically searched MEDLINE, EMBASE, and Cochrane from inception until June 2025. Eligible randomized and observational studies compared GLP-1RAs or bariatric surgery (each plus conventional care) against conventional management. Primary outcomes were the change in papilledema, visual acuity, and visual field. Secondary outcomes included body mass index (BMI), retinal nerve fiber layer (RNFL) thickness, monthly headache days, and risks of papilledema, visual disturbance, and headache. Pairwise random-effects meta-analyses and frequentist network meta-analysis (-scores) were performed. P
RESULTS: Out of 429 records, 8 studies were included. Versus conventional therapy, GLP-1RAs reduced BMI (mean difference -1.55 kg/m; 95% confidence interval [CI]: -2.13 to -0.97) and lowered risks of papilledema (relative risk [RR]: 0.47; 95% CI: 0.34-0.65), visual disturbance (RR: 0.48; 95% CI: 0.24-0.98), and headache (RR: 0.78; 95% CI: 0.69-0.88). Changes in papilledema severity and RNFL thickness were not different; visual acuity favored GLP-1RAs at the end of follow-up, whereas visual field values were worse at some time points. In indirect comparisons with bariatric surgery, no significant differences were detected across outcomes. 2
CONCLUSIONS: Adjunctive GLP-1RA therapy may be associated with weight loss and improved clinical/ophthalmic outcomes in IIH relative to conventional care, with a signal for worse visual fields at certain time points. Indirect comparisons suggest comparable efficacy to bariatric surgery. High-quality randomized trials are needed to define comparative effectiveness, safety, and optimal use.
