Routine peri-operative cessation of glucagon-like peptide-1 receptor agonists has unintended consequences

Abstract

We read with interest the study by Nersessian et al., in which they showed that semaglutide use was associated with increased residual gastric content in patients having surgery [1]. They call for urgent revision of current societal guidelines recommending a 1-week pre-operative discontinuation interval of semaglutide in patients undergoing elective procedures under anaesthesia [1]. It is salutary to note that the exclusion criteria for the study were very extensive and included patients with diabetes; hiatus hernia; previous gastric surgery; chronic renal failure; and the pre-operative use of medication known to affect gastric emptying. The exclusion of so many patients and conditions has an impact on the suitability and applicability of the results of this study to influence routine practice.

There are many other drugs that can delay gastric emptying. These include opioids; anticholinergics; calcium channel blockers; and tricyclic antidepressants, and there is no call for revised societal guidelines on the peri-operative use of these drugs to reduce the risk of pulmonary aspiration. Furthermore, the evidence linking any potential increased residual gastric content associated with glucagon-like peptide-1 receptor agonist (GLP-1 RA) use to an increased risk of aspiration and regurgitation is lacking.

Peri-operative cessation of GLP-1 RAs has unintended consequences, particularly when used for the treatment of diabetes. This includes increasing the risk of further delays to surgery due to deranged pre-operative glucose and harm from peri-operative hyperglycaemia [2]. Having the patient reviewed by a diabetologist and replacing the GLP-1 RAs with alternative drugs in the peri-operative period is an option, but this may lead to further delays in surgery and harm from hypoglycaemia [2].

In response to the American Society of Anesthesiologists consensus-based guidance on the pre-operative management of patients on GLP-1 RAs, the Centre for Perioperative Care released UK guidance in September 2023 [3]. This stated that anaesthetists should undertake individualised clinical assessment and precautions, which include regional anaesthesia; tracheal intubation; modified rapid sequence intubation; ramped position; awake tracheal extubation; avoidance of first-generation supraglottic airway devices; and pre-operative gastric ultrasound [3]. A more recent clinical practice guideline also supports this stance, but with other caveats, including greater emphasis on shared decision-making and a pre-operative liquid diet for the 24 h before surgery for those at high risk [4]. It is noteworthy that the American Society of Anesthesiologists has also approved this new guideline [4].

Rather than curtailing the peri-operative use of GLP-1 RAs, we argue that the study by Nersessian et al. reinforces the stated position of the Centre for Perioperative Care, and other societies, that GLP-1 RAs should be continued in the peri-operative period, but suitable precautions are taken.