GLUCAGON-like peptide-1 receptor agonists (GLP-1RA), which work by reducing hyperglycaemia and enhancing satiety, also delay gastric emptying. This can lead to an increased risk of aspiration during procedures requiring sedation or anaesthesia. Reports of pulmonary aspiration and difficulties in diagnosing gastrointestinal complications in the perioperative period have highlighted the need for clear clinical guidance to manage these patients safely.
A new multisociety clinical guide seeks to address these challenges by emphasising shared decision-making among patients and care teams to balance the risks and benefits of GLP-1RA therapy during the perioperative period.
Several factors have been identified as increasing the risk of delayed gastric emptying in patients taking GLP-1RAs. Patients in the escalation phase of therapy are at higher risk compared to those in the maintenance phase, as the body’s adjustment to the medication is still ongoing. Higher doses of GLP-1RAs are also associated with more pronounced gastrointestinal side effects, such as nausea, vomiting, and constipation. Additionally, weekly formulations of these drugs tend to produce more gastrointestinal side effects than daily formulations, further elevating the risk.
Patients presenting with symptoms suggestive of delayed gastric emptying, including nausea, vomiting, abdominal pain, or constipation, require careful evaluation. Underlying medical conditions such as gastroparesis or bowel dysmotility may exacerbate these risks and should also be considered during preoperative assessments. Conducting these evaluations well in advance of surgery allows care teams to implement strategies such as dietary modifications or medication adjustments. For some high-risk patients, discontinuing GLP-1RAs might be necessary, although this approach must be carefully weighed against the potential for metabolic complications, including hyperglycaemia. Current guidance suggests holding daily formulations on the day of surgery and weekly formulations up to a week before the procedure, though evidence on the optimal timing remains limited.
To further minimise aspiration risk, the guide recommends several interventions. A preoperative liquid diet for at least 24 hours, akin to protocols used for colonoscopy or bariatric surgery, can be employed in patients at risk of delayed gastric emptying. In cases where clinical concern about gastric contents persists, point-of-care gastric ultrasounds may help assess aspiration risk. When delayed gastric emptying is confirmed or strongly suspected, rapid sequence induction of general anaesthesia with tracheal intubation can be considered to prevent aspiration, though this should be weighed against the risks of procedure cancellation.
Given the rapid evolution of GLP-1RA therapies and the emergence of dual and triple agonists, this guidance is intended to provide a flexible framework rather than rigid protocols. The recommendations highlight the importance of individualised care, balancing safety with the therapeutic benefits of these medications to ensure optimal surgical and procedural outcomes.
Ada Enesco, EMJ
Reference
Kindel TL et al. Multisociety clinical practice guidance for the safe use of glucagon-like peptide-1 receptor agonists in the perioperative period. Surg Obes Relat Dis. 2024;20(12):1183-1186.
