Anesthesiology, GI and obesity groups say most patients can continue GLP-1 drugs before elective surgery

Five medical organizations released joint clinical practice guidance on October 29, 2024, on managing patients who take GLP-1 receptor agonists before elective procedures. The central recommendation: most patients should continue taking their GLP-1 drug, while those at highest risk for significant gastrointestinal side effects should follow a liquid diet for 24 hours before the procedure or take other measures depending on the circumstances ^[1].

The guidance came from the American Society of Anesthesiologists, the American Gastroenterological Association, the American Society for Metabolic and Bariatric Surgery, the International Society for Perioperative Care of Patients with Obesity, and the Society of American Gastrointestinal and Endoscopic Surgeons ^[1]. It was released in Chicago along with a corresponding letter to the editor in Anesthesiology by Girish P. Joshi, M.D., FASA, a coauthor of the guidance and vice chair of the ASA's Committee on Practice Parameters ^[1].

About one in eight U.S. adults uses a GLP-1 drug such as Ozempic (semaglutide), Wegovy (semaglutide), Saxenda (liraglutide) or Trulicity (dulaglutide) for diabetes, weight loss or heart problems ^[1]. These drugs delay stomach emptying, which can leave food in the stomach. During general anesthesia and deep sedation, that raises the risk that stomach contents are regurgitated and inhaled into the airways and lungs, which can cause aspiration pneumonia and can be fatal ^[1]. The guidance says the potential benefit of withholding the medication has to be weighed against the risks of stopping it, such as rising blood sugar in people with diabetes ^[1].

Which patients get extra precautions

Patients in the escalation phase of treatment, when the dose is being increased, are more likely to have delayed stomach emptying. That phase typically lasts four to eight weeks, depending on the drug and why it was prescribed. Elective surgery should be deferred and proceed only once the escalation phase has passed and GI side effects have dissipated, the guidance says ^[1].

Patients with GI symptoms — nausea, vomiting, abdominal pain, shortness of breath or constipation — should wait until symptoms dissipate before elective surgery ^[1]. People on a higher dose typically have more GI side effects and should follow a liquid diet for 24 hours before the procedure ^[1]. Other conditions that slow stomach emptying, such as Parkinson's disease, may further change the management plan ^[1].

Options other than stopping the drug

The care team can lower the risk of delayed stomach emptying by having the patient follow a liquid-only diet for 24 hours before surgery, adjusting the anesthesia plan, and using point-of-care ultrasound immediately before the procedure to check stomach contents in the highest-risk patients ^[1]. In rare cases, surgery should be delayed for patients whose risk is expected to decrease ^[1]. Patients at low risk for delayed stomach emptying who are having elective surgery can keep taking their GLP-1 drug ^[1].

Withholding a GLP-1 drug can be resource intensive, cost or insurance-prohibitive, and can have other negative effects such as changing blood sugar levels, the guidance notes. It also says withholding the drugs only for patients who are obese or overweight could constitute bias or discrimination and should be avoided ^[1].

“As anesthesiologists, we are committed to considering all factors to ensure patients get the best and safest care whenever anesthesia care is required,” ASA President Donald E. Arnold, M.D., FACHE, FASA, said in the announcement ^[1].

Why it matters for patients

The guidance says patients should work with their anesthesiologist, surgeon and prescribing care team to determine whether adjustments can be made so surgery can proceed, or whether the procedure should be delayed until the risk decreases ^[1]. That means the instructions a patient receives may depend on how far along they are in treatment, whether they have GI symptoms or are on a higher dose, and whether they have another condition that slows stomach emptying.

For patients with diabetes, continuing the drug avoids a stretch of higher blood sugar around a procedure. For patients whose drug is expensive or hard to obtain, it avoids a gap in supply ^[1].

The guidance does not specify a number of days to pause a GLP-1 drug before surgery, and it has not been reported how many hospitals or surgery centers will change their policies as a result. Whether the guidance changes insurance or scheduling practices also has not been disclosed.