Schaumburg, IL—Patients prescribed daily GLP-1 agonists should not take the drug on the day of any procedure/surgery, according to the American Society of Anesthesiologists (ASA). The ASA’s Task Force on Preoperative Fasting also recommends that patients on weekly dosing consider holding GLP-1 agonists a week prior to the procedure/surgery.

Those recommendations are in force for patients using GLP-1 agonists for any indication—type 2 diabetes mellitus (T2DM) or weight loss—and any dosage. It also does not matter what type of procedure or surgery is planned, the ASA advised.

GLP-1 receptor agonists are approved by the FDA for the treatment of T2DM and cardiovascular risk reduction in that cohort. Recently, prescriptions of GLP-1 receptor agonists for weight loss have burgeoned.

“The GLP-1 agonists are associated with adverse gastrointestinal [GI] effects such as nausea, vomiting and delayed gastric emptying,” according to the guidelines. “The effects on gastric emptying are reported to be reduced with long-term use. This is most likely through rapid tachyphylaxis at the level of vagal nerve activation.”

The panel noted that based on recent anecdotal reports, concerns have been raised that delayed gastric emptying from GLP-1 agonists can increase the risk of regurgitation and pulmonary aspiration of gastric contents during general anesthesia and deep sedation. “The presence of adverse gastrointestinal symptoms (nausea, vomiting, dyspepsia, abdominal distension) in patients taking GLP-1 agonists are predictive of increased residual gastric contents,” guideline authors pointed out.

The panel also issued guidelines for preoperative management in children. “The use of GLP-1 agonists in pediatrics has primarily been reported for the management of type 2 diabetes mellitus and obesity,” the panel noted. “The published literature on GLP-1 agonists in pediatrics is predominantly from pediatric patients 10-18 years old; concerns are similar to those reported in adults. During the conduct of general anesthesia/deep sedation, children on GLP-1 agonists have similar gastrointestinal adverse events at a rate similar to adults.”

To reach its conclusions, the task force reviewed the available literature on GLP-1 agonists and associated GI adverse effects, including concerns about delayed gastric emptying. “The evidence to provide guidance for preoperative management of these drugs to prevent regurgitation and pulmonary aspiration of gastric contents is sparse, limited only to several case reports,” the panel wrote. “Nevertheless, given the concerns of GLP-1 agonists-induced delayed gastric emptying and associated high risk of regurgitation and aspiration of gastric contents, the task force suggests the following for elective procedures. For patients requiring urgent or emergent procedures, proceed and treat the patient as ‘full stomach’ and manage accordingly.”

For both children and adults, if GLP-1 agonists prescribed for diabetes management are held for longer than the dosing schedule, the guidelines urge surgeons to consider consulting an endocrinologist for bridging the antidiabetic therapy to avoid hyperglycemia.

The panel further recommended that if GI symptoms, such as severe nausea/vomiting/retching, abdominal bloating, or abdominal pain, are present, surgeons should consider delaying elective procedures. If the patient has no GI symptoms and the GLP-1 agonists have been held as advised, the surgical team can proceed as usual.

In cases where the patient has no GI symptoms, but the GLP-1 agonists were not held as advised, the surgical team “should proceed with ‘full stomach’ precautions or consider evaluating gastric volume by ultrasound, if possible and if proficient with the technique. If the stomach is empty, proceed as usual. If the stomach is full or if gastric ultrasound inconclusive or not possible, consider delaying the procedure or treat the patient as ‘full stomach’ and manage accordingly.”

Because there is no evidence to suggest the optimal duration of fasting for patients on GLP-1 agonists, ASA suggested following its current fasting guidelines until more evidence is available.

The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.

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