Improvement of small fiber neuropathy assessed by corneal confocal microscopy following semaglutide treatment: a case report and literature review.

Diabetic peripheral neuropathy (DPN) is the most common chronic complication of type 2 diabetes (T2D) and a major predisposing factor for the development of diabetic foot, one of the most devastating diabetes-related conditions associated with substantial morbidity and mortality. To date, no pharmacological therapy has been shown capable of preventing, halting, or reversing neuropathic damage. We report the case of a 57-year-old man with T2D and obesity (BMI 35.2 kg/m²) who presented with symptoms and signs of DPN, including a neuropathy symptom score (NSS) of 3/9, a neuropathy disability score (NDS) of 3/10, and a vibration perception threshold (VPT) of 22 volts (V) bilaterally. In vivo corneal confocal microscopy (CCM) was performed to further evaluate small fiber involvement. Despite adequate glycemic control (HbA1c 6.6%), semaglutide was initiated to optimize metabolic status and promote weight loss. After 6 months of treatment, both BMI and HbA1c had improved, while NSS, NDS, and VPT remained unchanged. Repeat CCM demonstrated improvement across all corneal nerve parameters. This case suggests that semaglutide-associated metabolic improvement, or a direct semaglutide effect on small fiber integrity, may contribute to early regeneration of small nerve fibers in DPN. Further studies are urgently needed to determine whether semaglutide has a therapeutic role in the management of DPN.