CHICAGO – Most patients should continue taking their glucagon-like peptide-1 (GLP-1) receptor agonists before elective surgery, suggests new clinical guidance released by the American Society of Anesthesiologists (ASA), American Gastroenterological Association, American Society for Metabolic and Bariatric Surgery, International Society of Perioperative Care of Patients with Obesity, and the Society of American Gastrointestinal and Endoscopic Surgeons. Patients at the highest risk for significant gastrointestinal (GI) side effects should follow a liquid diet for 24 hours before the procedure or other measures, depending on the specific circumstances.
About one in eight U.S. adults use GLP-1 drugs such as Ozempic® (semaglutide), Wegovy® (semaglutide), Saxenda® (liraglutide) and Trulicity® (dulaglutide) for diabetes, weight loss or heart problems. Because GLP-1 drugs delay stomach emptying (which can cause significant adverse GI symptoms such as nausea, vomiting, constipation and bloating) there may be residual food in the stomach that increases the risk for regurgitation and aspiration into the airways and lungs during general anesthesia and deep sedation, which can cause potentially fatal aspiration pneumonia. However, the guidance notes the potential benefit of withholding the medication so patients can have surgery needs to be balanced with the potential risks, such as increasing blood sugar levels in those with diabetes. The goal is to ensure patients can have surgery safely without removing the benefit of their GLP-1 drugs any longer than necessary.
Patients should work with their health care team, i.e., their anesthesiologist, surgeon and prescribing care team, to determine if adjustments can be made so surgery can proceed or if the procedure needs to be delayed until the risk decreases, recommends the guidance and a corresponding letter to the editor in Anesthesiology by Girish P. Joshi, M.D., FASA, a coauthor of the guidance and vice chair of ASA’s Committee on Practice Parameters.
The guidance notes the team can minimize the risk of delayed stomach emptying by having the patient follow a liquid-only diet for 24 hours before surgery, adjusting the anesthesia plan to minimize aspiration risk and using point-of-care ultrasound right before the procedure to assess stomach contents in patients at highest risk. In rare cases, surgery should be delayed in patients whose risk is expected to decrease. Patients at low risk for delayed stomach emptying who are having elective surgery can continue to take their GLP-1 drugs, the guidance says.
“As anesthesiologists, we are committed to considering all factors to ensure patients get the best and safest care whenever anesthesia care is required,” said ASA President Donald E. Arnold, M.D., FACHE, FASA. “In many cases, patients with scheduled procedures should continue taking the drug. Scheduling of elective procedures should integrate awareness of circumstances when the risk of delayed stomach emptying is highest, such as when the patient is just beginning the drug and the dose is being increased, as well as for patients with significant GI symptoms. Ideally, these risk factors should be assessed and minimized in advance, so the surgery or procedure can safely proceed.”
The team should take into account patient-specific risk factors for delayed stomach emptying and consider the following guidance for patients at highest risk:
- Patients in the escalation phase of GLP-1 drugs (early in treatment) are more likely to have delayed stomach emptying. The escalation phase (when the patient is given increasing doses of the GLP-1 drug) typically lasts four to eight weeks, depending on the drug and the reason it has been prescribed. Elective surgery should be deferred and only proceed once the escalation phase has passed and GI side effects have dissipated.
- Patients who have GI symptoms, including nausea, vomiting, abdominal pain, shortness of breath or constipation should wait until their symptoms have dissipated before proceeding with elective surgery.
- Patients on a higher dose of the GLP-1 drug typically have more GI side effects and should follow a liquid diet for 24 hours before the procedure.
- Patients with other medical conditions that slow stomach emptying, such as Parkinson’s disease may further modify the perioperative management plan.
While some providers may believe it’s safest to pause the GLP-1 drug for surgery, they should consider whether the risk of delayed stomach emptying outweighs any risk that stopping the GLP-1 drug may have on the condition being addressed by the GLP-1 drug, the guidance says. The team should also consider other factors, including that withholding the GLP-1 drug may be resource intensive, cost or insurance-prohibitive, and risk other negative side effects such as impacting blood sugar levels. Further, the guidance notes withholding GLP-1 drugs only for obese and overweight patients could constitute bias or discrimination and should be avoided.
THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS
Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 58,000 members organized to advance the medical practice of anesthesiology and secure its future. ASA is committed to ensuring anesthesiologists evaluate and supervise the medical care of all patients before, during, and after surgery. ASA members also lead the care of critically ill patients in intensive care units, as well as treat pain in both acute and chronic settings.
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