AUGUST 18, 2025
Originally published by our sister publication Anesthesiology News
PHOENIX—From the value of nonsteroidal anti-inflammatory drugs (NSAIDs) for opioid-sparing pain relief, to the need to follow evidence, not emotion, in clinical decision-making for patients taking glucagon-like peptide-1 (GLP-1) receptor agonist drugs undergoing weight-loss surgery, Girish P. Joshi, MD, MBBS, presented an overview of the topics he considered to be most important published in the past year, at the 2025
Originally published by our sister publication Anesthesiology News
PHOENIX—From the value of nonsteroidal anti-inflammatory drugs (NSAIDs) for opioid-sparing pain relief, to the need to follow evidence, not emotion, in clinical decision-making for patients taking glucagon-like peptide-1 (GLP-1) receptor agonist drugs undergoing weight-loss surgery, Girish P. Joshi, MD, MBBS, presented an overview of the topics he considered to be most important published in the past year, at the 2025 annual meeting of the Society for Ambulatory Anesthesia.
“This year, there were studies that should challenge us to reconsider our pharmacological approaches in a number of clinical scenarios in anesthesiology,” said Joshi, a professor of anesthesiology and pain management at The University of Texas Southwestern Medical Center, in Dallas.
Here are the speaker’s selections of the most important takeaways from the literature, along with his commentaries.
Multi-Society Clinical Practice Guidance for the Safe Use of Glucagon-Like Peptide-1 Receptor Agonists in the Perioperative Period (Surg Endosc 2025;39[1]:180-183)Joshi cited poorly designed studies that claimed to illuminate associations, or a lack thereof, between GLP-1 drugs, delayed gastric emptying and aspiration pneumonia to make a simple but significant point: “Garbage in, garbage out.”
“I want to impress upon you that we do not have very good data, even if GLP-1 drugs are associated with delayed gastric emptying or residual gastric content,” he added. “Delayed gastric emptying leading to regurgitation is one problem; regurgitation leading to aspiration is another issue; and aspiration becoming clinically significant is a third issue.”
In other words, he said, any link between GLP-1 drugs and pulmonary aspiration is multifactorial and therefore extremely difficult to study.
Given the absence of reliable data from robust studies, Joshi counseled that anesthesiologists should behave prudently and avoid what he called “the knowing/doing gap,” which causes anesthesiologists to make decisions based on emotions rather than evidence—in this case, stopping GLP-1 drugs for a week prior to surgery simply because it feels like the right thing to do.
As an alternative, Joshi proposed a multidisciplinary algorithm that involves identifying patients at high risk for delayed gastric emptying and prescribing a 24-hour liquid diet prior to surgery for those patients.
“It’s not perfect, but the bottom line is that this is what we have,” he said. “Each institution will have to decide how to proceed. But stopping the drug is not the answer.”
Postoperative Outcomes Among Sodium-Glucose Cotransporter 2 Inhibitor Users (JAMA Surg 2025;160[6]:681-689)With regard to how to manage the risk for diabetic ketoacidosis in patients taking sodium-glucose cotransporter-2 (SGLT-2) inhibitors, Joshi cited research highlighting disparate recommendations between North American and European institutions, with the former recommending stopping for three to four days prior to surgery and the latter for 24 hours (Anaesthesia 2025;80[4]:412-424).
Joshi noted that the recommendations are based on the same evidence; however, the European guidelines are stratified by risk, while the American ones are not. He recommended taking a page from the European playbook and making the decision based on risk, and he presented an algorithm for doing so.
Nonsteroidal Anti-inflammatory Drugs in the Perioperative Period: Current Controversies and Concerns (Br J Anaesth 2025;134[2]:294-296)In this editorial, Joshi and his co-authors considered current controversies and concerns about the use of NSAIDs in the perioperative period, concluding that the avoidance of NSAIDs due to fear of adverse effects is not supported by the evidence. Instead, NSAIDs are a critical and frequently underused component of multimodal analgesia.
“We know that NSAIDs provide excellent pain relief, decreasing opioid requirements by 30% to 40%,” Joshi said. “But often the immediate response from surgeons, even from first-year surgery residents, is to avoid using them.”
This reluctance is based on a misunderstanding of three prominent studies, he said. He noted that NSAIDs are contraindicated in certain high-risk patients—most notably acute kidney injury, as well as patients undergoing closed-cavity surgery or major spine surgery with bleeding issues.
“Otherwise, there are really no good contraindications for the use of NSAIDs in the perioperative period, and generally speaking, these drugs should be used fairly liberally,” he said.
Joshi also noted that, following a provision in the NOPAIN (Non-opioids Prevent Addiction in the Nation) Act that is in effect this year, the Centers for Medicare & Medicaid Services will increase funding for the use of nonopioids in pain management.
Peri-Operative Glucocorticoids: A Panacea for Postoperative Pain Management? (Eur J Anaesthesiol 2025;42[7]:584-586)The evidence supports the use of low-dose dexamethasone, 8 to 10 mg, in virtually all patients, except where contraindicated, Joshi said. However, in patients identified as susceptible to a high surgical stress response, a higher dose of up to 1 mg/kg can improve postoperative recovery.
“The key here is that not all patients have the same surgical stress response, so we need to identify the patients who will benefit—those with high baseline inflammatory response or high pain responders—beforehand,” he said.
Intra- and Interindividual Variability in Fasted Gastric Content Volume (Neurogastroenterol Motil 2024;36[11]:e14904)In this study, the researchers used rapid MRI scans to study the presence of retained gastric contents, with results that upend common assumptions.
“They found a huge amount of variability, not only between patients, but also in the same patient at different days and time points,” Joshi said, noting that the study found no associations with age, weight, size or health. “We assume that all patients with diabetes have delayed gastric emptying, and that’s not true.”
The authors recommended performing gastric ultrasound to assess patients in high-risk populations, a recommendation that Joshi endorsed.
Risk of Acute Complications With Rocuronium Versus Cisatracurium in Patients With Chronic Kidney Disease: A Propensity-Matched Study (Anesth Analg 2025;140[5]:1004-1011)Joshi presented multiple studies pertaining to sugammadex, all of which pointed to the need to exercise caution. The first study found an elevated risk for complications in patients who received a combination of sugammadex and rocuronium compared with patients receiving cisatracurium and neostigmine.
He presented findings from four more studies showing, first, that the use of neuromuscular blockade—muscle relaxants—rose substantially among pediatric patients at a single institution following the introduction of sugammadex; and second, that even when neuromuscular blockade is reversed by using sugammadex, there is an elevated incidence of impaired ventilatory response.
“We should not be using muscle relaxants liberally and thinking ‘oh, I can always reverse it,’” he said. “We should use it prudently. The only time you need to repeat the dose after induction would be situations in which patient movement can be detrimental.”
By Ajai Srinivas
Joshi reported honoraria for consulting from Harisco-USA Pharmaceuticals and Vertex Pharmaceuticals.
