Nicotinamide Supplementation Associated with Reduced Risk of POAG in Those with OHT

Systemic nicotinamide may serve as a prophylactic therapy to delay or prevent the onset of POAG, but many questions on clinical guidance still remain. Photo: Bisant Labib, OD. Click image to enlarge. While traditional management of patients with ocular hypertension relies strictly on lowering intraocular pressure (IOP) to delay primary open-angle glaucoma (POAG) onset, a considerable proportion of patients still convert to glaucomatous optic neuropathy. Systemic nicotinamide (vitamin B3) has emerged as a potential metabolic prophylactic intervention to prevent conversion. Clinical interest in supplementation has focused primarily on its neuroprotective capacity (by supporting mitochondrial function) to rescue compromised retinal ganglion cells and enhance visual function in patients with established glaucoma. However, its potential utility as a prophylactic intervention represents a distinct, novel approach to managing glaucoma and those at risk for it.In a study published yesterday in JAMA Ophthalmology, a team used 20 years of data from the TriNetX US Collaborative Network to determine whether systemic nicotinamide supplementation is associated with a reduced risk of POAG diagnosis and delayed medical or surgical escalation in patients with elevated IOP.1 The researchers’ findings suggest that it may indeed be associated with a reduced risk.“By potentially delaying POAG diagnosis and decreasing the rate of subsequently prescribed medical and laser interventions, nicotinamide represents a promising adjunctive strategy complementary to standard IOP-lowering therapy,” the study authors suggested in their paper.The propensity score-matched sample included 2,920 patients, with 1,460 in each cohort. In the nicotinamide group, the mean age was 54.4 and 57.9% were women. In the control group, the mean age was 54.9, and 59.5% were women. Patients with a primary diagnosis of ocular hypertension and at least one prior health care encounter were included, excluding those with a history of open-angle glaucoma, laser therapy or glaucoma topical therapies.Over a mean follow-up of 3.7 years, POAG diagnosis occurred in 51 patients in the nicotinamide group (3.5%) compared with 132 patients in the control group (9.0%; hazard ratio, HR: 0.34), representing a relative risk reduction of 66% and an absolute risk reduction of 5.5% in the nicotinamide cohort. Topical IOP-lowering therapy was initiated in 198 patients in the nicotinamide group (13.6%) compared with 309 patients in the control group (21.2%, HR: 0.57). Laser trabeculoplasty was performed in 12 patients in the nicotinamide group (0.8%) vs. 28 patients (1.9%) in the control group (HR: 0.38).The researchers did note that real-world nicotinamide dosage, formulation selection and true frequency of use cannot be verified from electronic health record records alone, and the optimal neuroprotective dose remains unknown. Also, patients with documented nicotinamide use may also engage in unmeasured health-seeking behaviors that independently contributed to better outcomes. Variables such as diet, exercise and wellness practices were not captured in any large-scale real-world database, and addressing this bias definitively requires a randomized clinical trial.A commentary also published in JAMA Ophthalmology noted that nicotinamide and niacin are widely available over-the-counter supplements and their use may not be consistently documented in electronic medical records or prescription databases.2 “Coding accuracy is a major concern,” wrote the commentary author, who pointed out that the OHT diagnosis itself was questionable in up to 39% of cases. “The variability in terminology and billing practices for glaucoma suspect and early glaucoma further compounds this issue.” Also, critical clinical parameters such as optic nerve and RNFL evaluation, visual fields, central corneal thickness and IOP measurements are often unavailable or inconsistently documented in large administrative databases. “Without these data, it is difficult to establish a reliable clinical baseline or adjust for disease severity.”Still, the commentary concluded that, despite these limitations, the authors should be commended for using a large real-world dataset to explore a clinically relevant question.Neither the study or the commentary advises doctors to recommend nicotinamide supplements to their patients, deferring instead to ongoing prospective studies that may in time clarify a potential role for this intervention. Click here for the journal source. 1. Muayad J, Sallam AB, De Francesco T, et al. Nicotinamide supplementation and primary open-angle glaucoma in patients with ocular hypertension. JAMA Ophthalmol. July 9, 2026. [Epub ahead of print]. 2. Law SK. Nicotinamide and risk of glaucoma within large-scale commercially available data. JAMA Ophthalmol. July 9, 2026. This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.