ASA Urges Withholding GLP-1 RA Therapy Prior to Elective Procedures

Michael W. Champeau, MD
Credit: American Society of Anesthesiologists

The American Society of Anesthesiologists (ASA) has released new guidance recommending the withholding of GLP-1 receptor agonists ahead of elective procedures or surgeries.

The new guidance, which was composed by of members of the ASA’s Task Force on Preoperative Fasting, comes as a result of the growing popularity of agents within the class and includes recommendations addressing potential risk of regurgitation and aspiration based on available literature.

“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,” said Michael W. Champeau, MD, president of the ASA and an adjunct clinical professor of Anesthesiology, Perioperative and Pain Medicine at Stanford University.² “These complications can be serious, so we are providing guidance on when GLP-1 agonists should be stopped in advance of an elective procedure.”

The rise of GLP-1 receptor agonists has taken the medical community by storm. A known staple in the armamentariums of endocrinologists for years, the class has gained additional popularity in recent years for its weight loss benefits.³ This increase in popularity, combined with challenges imposed by the COVID-19 pandemic, has resulted in shortages of agents within the class, with both dulaglutide and semaglutide listed as being “currently in shortage” in the FDA’s drug shortages database as of July 13, 2023.⁴

Although the class has demonstrated benefit for a multitude of conditions and seen a historic rise in popularity, use of GLP-1 receptor agonists is not without potential risk for adverse events, namely adverse gastrointestinal effects, including nausea, vomiting, and delayed gastric emptying.¹

Citing recent anecdotal reports purporting an association of delayed gastric emptying with use of GLP-1 receptor agonists and increased risk of regurgitation and pulmonary aspiration during general anesthesia and deep sedation, the ASA task force set forth to provide the community with guidance on use leveraging available literature on GLP-1 agonists and associated gastrointestinal adverse effects. The ASA underlined evidence of regurgitation and pulmonary aspiration of gastric contents is sparse limited only to several case reports and the guidance pertains only to patients with scheduled elective procedures.¹

For patients with scheduled elective procedures using GLP-1 receptor agonists is as follows:

Day(s) Prior to the Procedure:¹

• Consider holding GLP-1 receptor agonists on the day of the procedure/surgery. For patients on weekly dosing, consider holding GLP-1 receptor agonists for a week prior. The ASA notes this suggestion is irrespective of the indication, dose, or type of procedure/surgery.
• If GLP-1 receptor agonists prescribed for diabetes management are held for longer than the dosing schedule, consider consulting an endocrinologist for bridging antidiabetic therapy to avoid hyperglycemia.

Day of the Procedure:¹

• If gastrointestinal symptoms are present, including severe nausea/vomiting/retching, abdominal bloating, or abdominal pain, consider delaying the elective procedure and discuss the concerns of potential risk of regurgitation and pulmonary aspiration of gastric contents with the proceduralist/surgeon and the patient.
• If there are no gastrointestinal symptoms, and GLP-1 receptor agonists are held as advised, proceed as usual.
• If there are no gastrointestinal symptoms, but GLP-1 receptor agonists are not held, proceed with “full stomach” precautions or consider evaluating gastric volume by ultrasound. If the stomach is empty, proceed as usual. If the stomach is full of ultrasound is inconclusive or not possible, consider delaying the procedure or treat the patient as ‘full stomach’ and manage accordingly. Discuss the concerns of potential risk of regurgitation and pulmonary aspiration of gastric contents with the proceduralist/surgeon and the patient.

The task force highlighted there is no evidence for the optimal duration of fasting for patients on GLP-1 receptor agonists and suggests following current ASA fasting guidelines until adequate evidence exists. The task force noted, for those who need urgent or emergency surgery, full stomach precautions should be applied. In addition to the above recommendations, the ASA also called for further research into GLP-1 agonist medications and anesthesia.¹

The additional investigators included in this task force were Girish P. Joshi, MBBS, MD, Basem B. Abdelmalak, MD, Wade A. Weigel, MD, Sulpicio G. Soriano, MD, Monica W. Harbell, MD, Catherine I. Kuo, MD, Paul A. Stricker, MD, and Karen B. Domino, MD, MPH.¹

References:

1. American Society of Anesthesiologists Consensus-based guidance on preoperative management of patients (adults and children) on glucagon-like peptide-1 (GLP-1) receptor agonists. American Society of Anesthesiologists (ASA). June 29, 2023. Accessed July 13, 2023. https://www.asahq.org/about-asa/newsroom/news-releases/2023/06/american-society-of-anesthesiologists-consensus-based-guidance-on-preoperative.
2. American Society of Anesthesiologists (ASA). Patients taking popular medications for diabetes and weight loss should stop before elective surgery, asa suggests. Newswise. June 29, 2023. Accessed July 13, 2023. https://www.newswise.com/articles/patients-taking-popular-medications-for-diabetes-and-weight-loss-should-stop-before-elective-surgery-asa-suggests2.
3. Campbell P, Iapoce C. 10 years of obesity: A Decade of Advancement and challenges. HCP Live. June 23, 2023. Accessed July 13, 2023. https://www.hcplive.com/view/10-years-of-obesity-a-decade-of-advancement-and-challenges.
4. FDA drug shortages. FDA Drug Shortages. Accessed July 13, 2023. https://www.accessdata.fda.gov/scripts/drugshortages/.