Episode #161 GLP-1 Receptor Agonist Alert and All-New Consensus-Based Guidance

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. Last week, we talked about patients taking Semaglutide and other GLP-1 receptor agonist medications and the risk for aspiration. These are newer medications, and this has led to a new threat to anesthesia patient safety. We are continuing the conversation this week.

Before we dive into the episode today, we’d like to recognize Merck, a major corporate supporter of APSF. Merck has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Merck – we wouldn’t be able to do all that we do without you!”

Our featured article today is an article between issues. It is “Are Serious Anesthesia Risks of Semaglutide and Other GLP-1 Agonists Under-Recognized? Case Reports of Retained Solid Gastric Contents in Patients Undergoing Anesthesia” by William Beam and Lindsay Guevara. This article was published on June 8, 2023. To follow along with us, head over to APSF.org and click on the Newsletter heading. Second one down is Articles between issues. Then, scroll down until you get to our featured article today. I will include a link in the show notes as well.

Last week on the show, we focused on what glucagon-like peptide, or GLP-1 receptor agonists are, what medications are available, and why they are a threat to anesthesia patient safety. We also talked about the risk for delayed gastric emptying and having complex gastric contents when patients taking GLP-1 receptor agonists present for anesthesia and surgery. It is clear that these patients are at increased risk for aspiration.  We reviewed Table 2 from the article last week, but it so important to be aware of the risk factors for aspiration so we are going to run through them again today.

Here are the risk factors for aspiration.

• Esophageal Pathology which includes achalasia, previous esophagectomy, and tracheal esophageal fistula.
• High risk for ileus or bowel dysmotility including acute pancreatitis, recent intra-abdominal surgery, inpatients receiving opioids, and patients with prolonged bed rest.
• Intra-abdominal Obstruction from either gastric outlet, small bowel, or colonic.
• Emergency cases
• Cases with prolonged duration or complexity
• Pregnancy
• Active GI Bleed
• And finally, Known, suspected or induced gastroparesis and this includes longstanding diabetes, neuromuscular disorders, and medications including the topic for our podcast today, GLP-1 agonists.

And now, let’s continue with our featured article. The authors remind us about the two cases that we discussed last week. Remember, the first case was cancelled due to the high risk for aspiration after the anesthesia professional reviewed the patient’s history and symptoms and completed a gastric ultrasound. In the second case, the patient had high volume of complex intragastric contents as evidenced during placement of the orogastric tube and following emesis of solid gastric contents during emergence, but prior to extubation. This food was likely from 2-3 days before surgery given the patient’s reported history of fasting. This patient had several risk factors for increased gastric contents including taking a GLP-1 receptor agonist, long-standing diabetes, opioid use. The authors provide several additional cases related to GLP-1 receptor use and aspiration. First, a recent case report described a patient taking semaglutide who had an aspiration event with food remains during induction of anesthesia after fasting for 18 hours prior. In addition, there are several retrospective reviews of patients taking GLP-1 receptor agonists who had endoscopy procedures which revealed an increased risk for retained gastric contents. At the time on this APSF article, the Society of Perioperative Assessment and Quality Improvement consensus recommendation is to fold GLP-1 receptor agonists o the day of surgery. The optimal time period for withholding these medications has not been defined yet. Remember, many of these medications have a long half-life and withholding the medication for at least 5 half-lives prior to surgery and anesthesia in order to resume normal gastric function may not be feasible. Medications in this drug class also have important cardiovascular benefits and minimal risk for hypoglycemia so continued administration during the perioperative period is another consideration.

There is a call to action to take a closer look at the current fasting guidelines for patients taking GLP-1 agonists. This may be an appropriate time to perform a gastric ultrasound in order to evaluate for the presence of gastric contents prior to proceeding with surgery and anesthesia. If ultrasound is not available, it is important to consider the brand-new ASA guidance on preoperative management for patients taking these medications. You may need to weigh the risks for increased gastric contents and take necessary steps to decrease the risk for aspiration by performing a rapid sequence induction with gastric decompression prior to emergence. You must remain vigilant since patients with residual solid gastric contents are at risk for emesis and aspiration during emergence.

In early June at the Mayo Clinic, the practice for perioperative management for patients taking GLP-1 receptor agonists included the following:

• Patients are instructed to hold GLP-1 agonists on the morning of surgery.
• Procedures should not be delayed or cancelled if taking the day of surgery.
• Be aware of increased risk for full stomach when planning anesthetic management.
• No evidence-based practice recommendations regarding changes in management during moderate, deep sedation, and monitored anesthetic care.

Anesthesia professionals are likely to provide anesthesia care for patients taking GLP-1 receptor agonists given the increased use and expanded approval for weight loss. It is important to consider the potential for delayed gastric emptying and increased risk for aspiration. Going forward, more studies are needed to evaluate the safety of these medications throughout the perioperative period.

We aim to bring you the latest in perioperative patient safety, so we need to turn our attention to the June 29, 2023, publication of the “American Society of Anesthesiologists Consensus-Based Guidance on Preoperative Management of Patients (Adults and Children) on Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists” by Joshi and colleagues. I will include a link in the show notes as well.

The guidance includes a description of the FDA approval of GLP-1 receptor agonists for the treatment of type 2 diabetes and cardiovascular risk reduction and for weight low.  Side effects of these medications may include adverse gastrointestinal effects such as nausea, vomiting, and delayed gastric emptying which is likely related to rapid tachyphylaxis of vagal nerve activation. Keep in mind that the effects on gastric emptying may be reduced with long-term use. Given these side effects, anesthesia professionals are appropriately concerned about the increased risk for regurgitation and aspiration of gastric contents during anesthesia care. Symptomatic patients with nausea, vomiting, dyspepsia and abdominal distention while taking GLP-1 agonists are at increased risk for retained gastric contents. Pediatric patients between the ages of 10-18 years old may be taking these medications for type 2 diabetes and weight loss with similar adverse gastrointestinal events to adults. At this time there is limited evidence for this guidance with several case reports, but given the serious complications of regurgitation and aspiration, the ASA task force has made the following suggestions for elective procedures. Don’t forget that for patients undergoing urgent or emergent procedures, do not delay going to the operating room with full stomach precautions and appropriate management.

Here are the ASA considerations for patients undergoing elective procedures:

In the Day(s) Prior to the Procedure:

• For patients on daily dosing consider holding GLP-1 agonists on the day of the procedure/surgery. For patients on weekly dosing consider holding GLP-1 agonists a week prior to the procedure/surgery.
• This suggestion is irrespective of the indication (type 2 diabetes mellitus or weight loss), dose, or the type of procedure/surgery.
• If GLP-1 agonists prescribed for diabetes management are held for longer than the dosing schedule, consider consulting an endocrinologist for bridging the antidiabetic therapy to avoid hyperglycemia.

On the Day of the Procedure:

• If gastrointestinal (GI) symptoms such as severe nausea/vomiting/retching, abdominal bloating, or abdominal pain are present, consider delaying 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 the patient has no GI symptoms, and the GLP-1 agonists have been held as advised, proceed as usual.
• If the patient has no GI symptoms, but the GLP-1 agonists were not held as advised, 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. Discuss the concerns of potential risk of regurgitation and pulmonary aspiration of gastric contents with the proceduralist/surgeon and the patient.
• There is no evidence to suggest the optimal duration of fasting for patients on GLP-1 agonists. Therefore, until we have adequate evidence, we suggest following the current ASA fasting guidelines.15,16.

What is the policy at your institution? Are you following the new ASA consensus-based guidance? We hope that these considerations help you to be able to continue to provide safe anesthesia care and decrease the risk for aspiration.

Before we wrap up for today, we are going to hear from Beam again. He is going to share what he hopes to see going forward. Let’s take a listen.

[Beam] “The optimal approach to the perioperative management of patients on GLP one agonists has yet to be defined, and I suspect will continue to be a hot topic, although it may be appealing to recommend holding these medications prior to anesthesia.

The prolonged half-life of many of these medications makes this potentially impractical. Alternative recommendations to the NPO rules might be considered, for instance, at our institution in patients at high risk for residual gastric contents such as those with known gastroparesis or acsa, we routinely recommend a clear liquid diet for 48 hours prior to anesthesia.

This or other alterations to the fasting guidelines could be considered in this population as well. Finally, the routine use of gastric ultrasound may be very beneficial to help with decision making with some practice. The contents of the stomach of patients with normal gastric anatomy can determined at the bedside in just a few minutes.

In the near future, the three Mayo Clinic sites will be starting a prospective observational study using gastric ultrasound to determine the risk of retained gastric contents in patients on GLP one agonists undergoing anesthesia.”

[Bechtel] Thank you so much to Beam for contributing to the show today. We are looking forward to hearing more about the gastric ultrasound for patients on GLP-1 agonists study in the future. Are you performing a gastric ultrasound in the preoperative holding area to evaluate for retained gastric contents? Aspiration remains a big threat to anesthesia patient safety, and it is important to remain vigilant especially for patients who are at high risk for retained gastric contents.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

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Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

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