Multi-society consensus guidance on handling of GLP-1 therapy prior to general anaesthesia

Abstract

GLP-1 receptor agonists and dual GLP-1 and GIP agonists are widely used in people with type 2 diabetes and increasingly in people living with excess weight and/or obesity. Recent concerns have emerged regarding their potential increased risks of regurgitation, aspiration and airway compromise during anaesthesia. These concerns have led the American Society of Anaesthesia (ASA) to recommend holding these agents for 1 week for the injectable form and 1 day for the oral form before all procedures requiring anaesthesia in their 2023 guideline.¹ The latest FDA label change warns about the risk for pulmonary aspiration but recognizes that there is currently no adequate data to inform evidence-based recommendations to reduce risk in at-risk patients. The ongoing concerns and uncertainties have resulted in inconsistencies in the recommendations on appropriate guidance for the use of these therapies prior to general anaesthesia. This has also led to unnecessary cancellations and postponements of important procedures.

In view of this, a new joint-society guidance was published to provide some guidance on this issue. The five endorsing organizations are the American Society for Metabolic and Bariatric Surgery, American Society of Anaesthesiologists (ASA), American Gastroenterological Association, International Society of Perioperative Care of Patients with Obesity, and Society of American Gastrointestinal and Endoscopic Surgeons and was led by the ASA.²

The guideline highlights three main considerations. First is a need for preoperative assessment to identify individuals who are at an increased risk for delayed gastric emptying. These include patients who are undergoing the dose escalation phase rather than the maintenance phase and those on higher doses of treatment who are at a greater the risk for gastrointestinal (GI) side effects. In addition, GI side effects are more common with weekly versus daily formulations. Patients should be assessed for GI symptoms such as nausea, vomiting, abdominal pain, dyspepsia, and constipation all of which may suggest delayed gastric emptying. Finally, general assessment for risk of delayed gastric emptying beyond GLP-1 should include assessment for conditions associated with bowel dysmotility, gastroparesis and Parkinson's disease. These risk factors need to be assessed in advance to allow sufficient time to adjust preoperative care. Second, if there is concerns regarding the risk of delayed gastric emptying and therefore aspirations, a 24-h preoperative liquid diet, can be utilized to reduce risks. If retained gastric contents are a concern on the day of a procedure, point-of-care gastric ultrasound could be used to assess aspiration risk. Lastly, when concern about retained gastric contents exists on procedure day, 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.

It is anticipated that this guidance will allow individualization of care and risks rather than following blanket guidance to stop these therapies prior to general anaesthesia. It will also prevent unnecessary cancellations of procedures based on planned identification of at risk patients.