GLP-1RA therapy is associated with an increased risk of vestibular disorders, with a higher risk observed with semaglutide compared to tirzepatide. These findings suggest the need for vestibular symptom monitoring in patients receiving these medications and warrant further investigation into underlying mechanisms...
The increased risk of vestibular disorders linked to GLP-1RAs may involve multiple interconnected pathways. First, direct modulation of vestibular processing may occur through GLP-1 receptors expressed in the brainstem (vestibular nuclei complex) and cerebellum, which are critical regions for balance regulation [
27], potentially altering vestibulo-ocular reflex gain [
28,
29]. Second, fluid homeostasis disruption in the inner ear could arise from GLP-1RA-induced vasodilation (nitric oxide-dependent) and dysregulation of ion transport (Na+/K+-ATPase, aquaporins) [
30], destabilizing endolymph composition in semicircular canals and otolith organs [
31]. Third, metabolic stress in vestibular hair cells—highly dependent on mitochondrial bioenergetics—may be exacerbated by GLP-1RA effects on calcium handling and oxidative balance, particularly in patients with diabetes [
32]. Fourth, autonomic interactions are suggested by baroreflex modulation via nucleus tractus solitarius GLP-1 receptors, which may impair postural compensation [
33]. At the same time, tirzepatide’s reduced risk profile (HR = 3.19–4.55 vs. semaglutide HR = 4.02–4.95) implies that GIP co-activation mitigates sympathetic overdrive [
34]. Finally, rapid weight loss may induce proprioceptive recalibration demands, further compromising vestibular adaptation [
31] (
Figure 5).