Most patients may continue to safely take glucagon-like peptide-1 (GLP-1) receptor agonists as prescribed before undergoing elective surgery and gastrointestinal endoscopies, according to new clinical guidance released by five surgical and medical societies including the American Society for Metabolic and Bariatric Surgery (ASMBS), American Society of Anesthesiologists (ASA), American Gastroenterological Association (AGA), International Society of Perioperative Care of Patients with Obesity (ISPCOP) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).
"Our goal is to heighten awareness of a potential safety issue to prevent it," said Dr Ann M Rogers, President, ASMBS, the largest society for metabolic and bariatric surgeons in the US. "In most cases, patients can continue to take the drugs, however, individual risk factors for complications should be assessed prior to surgery before moving forward."
The guidance, 'Multisociety clinical practice guidance for the safe use of glucagon-like peptide-1 receptor agonists in the perioperative period', published online in Surgery for Obesity and Related Diseases, Surgical Endoscopy and Clinical Gastroenterology and Hepatology, however, cautioned that patients at high risk for significant gastrointestinal side effects should follow a liquid diet for 24 hours before a procedure and the anesthesia plan be adjusted accordingly. In rare cases, the procedure should be delayed.
GLP-1s delay gastric emptying and residual food or liquid in the stomach at the time of surgery with general anaesthesia, may increase the risk for serious complications including aspiration. On the other hand, withholding medication so patients can have surgery may be even riskier, prompting the new guidance. It is also important to note that the risk of delayed gastric emptying decreases over time for most patients on these medications.
"The purpose of this clinical practice guide is to offer unified, multi-society guidance for safely managing patients needing GLP-1RA therapy regardless of indication, which currently includes type 2 diabetes, overweight and obesity, and heart failure, during the periprocedural period,” the authors wrote.
The clinical guidance recommends that the use of GLP-1RAs in the perioperative period should be based on shared decision-making of the patient with procedural, anaesthesia and prescribing care teams balancing the metabolic need for the GLP-1RA with individual patient risk.
This can be achieved by developing the following multidisciplinary protocols/procedures appropriate for individual practices with care teams considering the following variables as elevating the risk of delayed gastric emptying and aspiration with the periprocedural use of GLP-1RA:
Escalation phase: The escalation phase, versus the maintenance phase, is associated with a higher risk of delayed gastric emptying with GLP-1RA usage
Higher dose: The higher the dose of GLP-1RA, the more likely the risk of gastrointestinal side effects
Weekly dosing: Gastrointestinal side effects are more common with weekly compared to daily formulation compounds
Presence of gastrointestinal symptoms: Symptoms suggestive of delayed gastric emptying and intestinal transit times may include nausea, vomiting, abdominal pain, dyspepsia and constipation
Medical conditions beyond GLP-1RA usage which may also delay gastric emptying: Patients on GLP-1RA should be evaluated for other medical conditions which may exacerbate gastrointestinal symptoms and delay gastric emptying, such as but not limited to bowel dysmotility, gastroparesis and Parkinson’s disease.
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.
In addition, the guidance states:
GLP-1RA therapy may be continued preoperatively in patients without elevated risk of delayed gastric emptying and aspiration. When an elevated risk of delayed gastric emptying and aspiration exist, withholding of GLP-1RAs should be balanced with the surgical and medical risk of inducing the potential for a hazardous, metabolic disease state, like hyperglycaemia. Further, bridging therapy off a GLP-1RA may be resource-intensive, cost or insurance prohibitive, and risk other adverse side effects like hypoglycemia. Finally, withholding GLP-1RA perioperatively only for patients with the diseases of overweight and obesity, without an indication, could constitute overweight and obesity bias, which should be avoided.
If the decision to hold GLP-1RAs is indicated given an unacceptable safety profile following shared decision-making in the preoperative period, the duration to hold therapy is unknown. At this time, it is suggested to follow the original guidance of the American Society of Anesthesiologists, holding the day of surgery for daily formulations, and a week prior to surgery for weekly formulations. All patients should still be assessed on the day of procedure for symptoms suggestive of delayed gastric emptying.
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 anaesthesia plan to consider rapid sequence induction of general anaesthesia for tracheal intubation.
Preoperative diet modification (preoperative liquid diet for at least 24 hours, as performed in patients undergoing colonoscopy and bariatric surgery) can be utilised in patients when there is concern for delayed gastric emptying based on clinical symptom review.
When clinical concern for retained gastric contents exists on the day of the procedure, point-of-care gastric ultrasound could be used to assess aspiration risk. This technology may be clinically limited based on institutional resources, interuser variability, and credentialing requirements.
When clinical concern for retained gastric contents exists or is confirmed on the day of the procedure, providers should engage patients in a shared decision-making model and consider the benefits and risks of rapid sequence induction of general anaesthesia for tracheal intubation to minimize aspiration risk versus procedure cancellation.
Safe continuation of surgery and gastrointestinal endoscopy, and prevention of procedure cancellation, for patients on GLP-1RAs can be prioritized following the recommendations above, as would occur for other patient populations with gastroparesis.
“While there has been an exponential increase in the clinical use of GLP-1RAs for various metabolic disease states in the past several years, little evidence exists to guide the best approach to managing these therapeutics perioperatively. This document may need modification with future generations of anti-obesity medications, including dual and triple agonists, and as additional evidence on the periprocedural management of these therapeutics is developed,” the guidance concludes. “However, at this time based on pharmacology and clinical experience, the following recommendations may be applied for current medications containing a GLP-1RA. For this reason, this multisociety clinical practice document should be considered guidance and not an evidence-based guideline, focusing on shared decision-making and balancing safety processes with therapeutic metabolic need for the safe continuation of surgical and procedural care in patients taking GLP-1RAs.”
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