JANUARY 16, 2025
Originally published by our sister publication Anesthesiology News
The majority of patients can continue treatment with glucagon-like peptide-1 receptor agonists (GLP-1 RAs) before undergoing elective surgeries, according to new multispecialty guidance from anesthesiologists, surgeons and gastroenterologists.
The recommendation is a reversal of 2023 guidance from the American Society of Anesthesiologists (ASA), which then advised a one-week or one-day break from injectable GLP-1 agents and
Originally published by our sister publication Anesthesiology News
The majority of patients can continue treatment with glucagon-like peptide-1 receptor agonists (GLP-1 RAs) before undergoing elective surgeries, according to new multispecialty guidance from anesthesiologists, surgeons and gastroenterologists.
The recommendation is a reversal of 2023 guidance from the American Society of Anesthesiologists (ASA), which then advised a one-week or one-day break from injectable GLP-1 agents and once-daily oral agents, respectively. That initial recommendation was in response to a number of case reports of regurgitation and aspiration in patients on GLP-1 RAs while under anesthesia due to the medication’s effects on delayed gastric emptying (Can J Anaesth 2023;70[8]:1397-1400).
The new guidance draws on the latest available evidence and was issued by five surgical and medical societies including the ASA, American Society for Metabolic and Bariatric Surgery (ASMBS), American Gastroenterological Association (AGA), International Society for the Perioperative Care of Patients with Obesity, and Society of American Gastrointestinal and Endoscopic Surgeons.
While stopping GLP-1 agents is not necessary for most patients, procedural, anesthesia and prescribing care teams should assess patients’ risk for delayed gastric emptying and make a shared decision if a short break from the medication is warranted.
“There have been inconsistencies in these clinical care documents, leading to uncertainty with providers on how to provide safe, effective and disease-equitable surgical and procedural care to patients taking GLP-1RAs,” the authors wrote. “Therefore, the purpose of this clinical practice guide is to offer unified, multisociety guidance for safely managing patients needing GLP-1RA therapy regardless of indication … during the periprocedural period.”
The Rise of GLP-1 RAs and Need for Unified Guidance
GLP-1 agents, including semaglutide (Ozempic/Rybelsus/Wegovy, Novo Nordisk) and liraglutide (Saxenda/Victoza, Novo Nordisk), have grown significantly in popularity across the United States in recent years. A May 2024 poll from the Kaiser Family Foundation found that 12% of Americans have reported taking the medication, which has revolutionized the care of patients with metabolic disease and has significant effects on weight loss (KFF Health Tracking Poll; 2024 May 10. kff.org/health-costs/poll-finding/kff-health-tracking-poll-may-2024-the-publics-use-and-views-of-glp-1-drugs/).
However, concerns have risen among providers for patients treated with these medications undergoing surgery, as they can cause delayed gastric emptying, therefore increasing the risk for aspiration. Common side effects of GLP-1 agents include nausea, vomiting, abdominal pain and constipation, which may complicate diagnosis and treatment in patients before and after surgery.
However, withholding GLP-1 agents comes with its own set of risks, inducing hyperglycemia.
“These guidelines were issued in response to the fact that millions of people are now taking these drugs, and there have been reports of issues like gastroparesis-related aspiration that needed to be addressed,” said Ann M. Rogers, MD, the president of ASMBS. “Our goal is to heighten awareness of a potential safety issue to prevent it.”
What the New Guidelines Say
Recommendation 1: Use of GLP-1RAs in the perioperative period should be based on shared decision-making of the patient with procedural, anesthesia and prescribing care teams balancing the metabolic need for the GLP-1RA with individual patient risk. This can be achieved by developing multidisciplinary protocols/procedures appropriate for individual practices.
To make this decision, providers should consider several factors, including:
“The assessment for these risk factors should occur with enough advance time prior to surgery to allow adjustments in preoperative care if indicated, including diet modification and evaluation of the feasibility of medication bridging if GLP-1RA discontinuation is indicated,” the authors wrote.
For patients who do not have an elevated risk for delayed gastric emptying and aspiration based on these considerations, GLP-1 therapy may be continued preoperatively.
Recommendation 2: The safe use of GLP-1RAs in the perioperative period should include efforts to minimize the aspiration risk of delayed gastric emptying. This can be achieved by preoperative diet modification and/or altering anesthesia plan to consider rapid sequence induction of general anesthesia for tracheal intubation.
To minimize the aspiration risk from delayed gastric emptying, the authors advise a 24-hour liquid diet for patients undergoing colonoscopy and bariatric surgery. A point-of-care gastric ultrasound (POCUS) could be used to assess aspiration risk. However, “this technology may be clinically limited based on institutional resources, interuser variability, and credentialing requirements,” the authors noted.
If the decision is made that there’s an unacceptable risk for delayed gastric emptying, providers should follow the original guidance from the ASA holding the day of surgery for daily agents, and a week before surgery for weekly agents.
“This concept of shared decision-making and developing local protocols is a foundational theme of this multisociety document, which in my opinion builds upon our prior AGA Rapid Clinical Practice Update on the Management of Patients Taking GLP-1 Receptor Agonists Prior to Endoscopy and other societal statements [Clin Gastroenterol Hepatol 2024;22(4):705-707],” said Andrew Wang, MD, a gastroenterologist at the University of Virginia, in Charlottesville, and one of the authors of the statement.
Concerns Remain
Current research on GLP-1 use before surgery is limited, primarily to case reports and retrospective studies with mixed results. Some studies describe an increased risk for aspiration during surgery while taking GLP-1 agents, while others show no elevated risk (Plast Reconstr Surg Glob Open 2023;11[11]:e5427; Diabetes Obes Metab 2024;26[8]:3128-3136).
The evolving and controversial nature of this research may lead some providers to question whether the new changes to recommendations are less safe, or no safer than previous guidance, said Travis Hiles, MD, an anesthesiologist in private practice in Kansas City, Mo.
“I think there is and will be continued fear of aspiration in surgical/procedural patients on GLP-1 agonists,” he said. “When a patient aspirates it is a very serious situation that can be deadly. We strive to make surgery as safe as possible daily, and I personally think the new recommendations have added new specifics, such as standardized preoperative assessment, liquid diet and POCUS, that make taking care of patients on GLP-1 agonists safer while weighing the risk of stopping.”
Recommendations Will Continue to Evolve
Research into the effects of GLP-1 agents on patients is ongoing, and the authors of the report said updates and changes in guidance should be expected as new evidence is revealed.
“It’s key that we understand that the ASA’s prior document, our AGA Clinical Practice Update and this multisociety document should be considered guidance, as none of these documents are evidence-based guidelines,” Wang said. “As new research emerges some of this guidance might be modified in the future.”
—By Ashley Welch
Hiles and Rogers reported no relevant financial disclosures. Wang owns publicly traded stock in GE HealthCare Technologies and Pfizer.
