ASA: Hold GLP-1 Agonists Before Elective Surgery

Patients on GLP-1 receptor agonists should stop taking them prior to elective surgery due to concerns over increased risk for regurgitation and pulmonary aspiration of gastric contents while under general anesthesia, according to new guidance from the American Society of Anesthesiologists (ASA).

As detailed in the ASA's Task Force on Preoperative Fasting statement this week, patients on one of the once-weekly injectable GLP-1 agents should not take their medication a week prior to surgery, and those on a once-daily agent should not take their medication the day of surgery, said Task Force Chair Girish P. Joshi, MBBS, MD, of the University of Texas Southwestern Medical Center in Dallas, and colleagues.

These recommendations apply to both adults and children on a GLP-1 receptor agonist. It also applies to all patients on an agent in this class, regardless of the indication (type 2 diabetes, obesity, etc.).

If patients with diabetes need to halt medication for longer than the dosing schedules, it's advised that they consult an endocrinologist on the possible use of other antidiabetic therapies to avoid hyperglycemia.

"While there is currently a lack of scientific data on how GLP-1 receptor agonists affect patients having surgery and interact with anesthesia, we've received anecdotal reports that the delay in stomach emptying could be associated with an increased risk of regurgitation and aspiration of food into the airways and lungs during general anesthesia and deep sedation," explained ASA President Michael W. Champeau, MD, in a statement.

"These complications can be serious," Champeau added, "so we are providing guidance on when GLP-1 agonists should be stopped in advance of an elective procedure."

While these agents shot to popularity for their metabolic effectiveness, they're also notorious for adverse gastrointestinal side effects. Adverse events commonly associated with the class include nausea, vomiting, diarrhea, and constipation due to delayed gastric emptying.

"The effects on gastric emptying are reported to be reduced with long-term use," the ASA guidance noted. "This is most likely through rapid tachyphylaxis at the level of vagal nerve activation."

On the day of surgery, if the patient presents with severe gastrointestinal symptoms like nausea, vomiting, or abdominal pain or bloating, clinicians should consider delaying elective procedures.

If patients present with no gastrointestinal events, but they didn't hold their mediation according to the recommendations, "full stomach" precautions should be taken and evaluation of gastric volume via ultrasound should be considered. From there, if the stomach is empty, the procedure can continue as scheduled. If the ultrasound shows the stomach is full or is inconclusive, the procedure should perhaps be delayed or the patient should be treated as a "full stomach" patient.

If the GLP-1 agent was held appropriately and the patient has no gastrointestinal events, the procedure should continue as planned.

As for a patient on one of these agents who requires an emergent or urgent procedure, healthcare providers should proceed as if the patient has a full stomach.

"There is no evidence to suggest the optimal duration of fasting for patients on GLP-1 agonists," the guidance stated. "Therefore, until we have adequate evidence, we suggest following the current ASA fasting guidelines."

The GLP-1 class of medications has seen a boom in recent years, first developed as a treatment for type 2 diabetes before becoming popular as weight-loss drugs. Some of the most commonly prescribed agents belonging to this class include semaglutide (Ozempic, Rybelsus, Wegovy), liraglutide (Victoza, Saxenda), dulaglutide (Trulicity), and tirzepatide (Mounjaro), among others.

At this year's American Diabetes Association (ADA) Scientific Sessions, there was a slew of new GLP-1-containing compounds that reached milestone weight losses in clinical trials, including retatrutide -- which demonstrated up to a 24.2% body weight loss, the most in any obesity trial thus far -- as well as survodutide and orforglipron.

Currently, the ADA's Standards of Care in Diabetes 2023 doesn't include any recommendations for GLP-1 receptor agonists prior to surgery, stating that "there are no data on the use and/or influence of [GLP]-1 receptor agonists or ultra-long-acting insulin analogs on glycemia in perioperative care."

However, the ADA does advise that SGLT2 inhibitors be discontinued 3 to 4 days prior to surgery, while metformin should be held the day of surgery.

"Hold any other oral glucose-lowering agents the morning of surgery or procedure and give half of NPH [neutral protamine Hagedorn] dose or 75-80% doses of long-acting analog or insulin pump basal insulin based on the type of diabetes and clinical judgment," the ADA advised.

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