GLP-1 Receptor Agonists: Mitigating Surgical Aspiration Risk

Glucagon-like peptide-1 (GLP-1) receptor agonists are gaining popularity as a treatment for Type 2 diabetes and, in some patients, obesity. Examples of drugs in this class include semaglutide, exenatide, lixisenatide, liraglutide, albiglutide, and dulaglutide. These medications work, in part, by delaying gastric emptying which can be problematic for patients who undergo or who are planning to undergo elective surgery.

Prevention of perioperative pulmonary aspiration is accomplished by careful evaluation and preparation of the patient which typically includes preoperative fasting and the administration of medications to reduce the acidity of stomach contents. Recent anecdotal reports have raised concern that delayed gastric emptying associated with GLP-1 receptor agonists can increase the incidence of regurgitation and subsequent aspiration of stomach contents during general anesthesia and deep sedation resulting in serious lung injury. On June 29, 2023, in response to these concerns, the American Society of Anesthesiologists (ASA) issued consensus-based guidance regarding preoperative management of patients who are taking GLP-1 receptor agonists. These guidelines are designed to reduce the incidence of adverse events related to perioperative aspiration in patients who are taking these types of drugs. 

Risk recommendations:

Delayed gastric emptying can pose a surgical risk for patients who are taking GLP-1 receptor agonists by increasing the risk of aspiration-related lung injury. Consider the following when managing surgical patients who are taking GLP-1 receptor agonists: 

• Complete a thorough perioperative assessment. A perioperative assessment should include a thorough review of records, a physical examination, and a patient interview. If the patient is experiencing gastrointestinal symptoms, consider delaying surgery and discuss your concerns with the patient and the proceduralist and/or referring provider.
• Reconcile medications. Obtain a complete list of the medications the patient is currently taking and be sure to include the patient in the reconciliation process. Patients who take GLP-1 receptor agonists may obtain prescriptions from online providers and/or pharmacies which may not input data to the electronic medical record. Accordingly, patients should be specifically queried regarding their use of GLP-1 receptor agonists using commonly known brand names (e.g., Ozempic, Trulicity). Ensure that the patient’s medication list is accurate and updated on every visit.
• Update your knowledge. Dosage schedules for GLP-1 receptor agonists vary so it is important to be familiar with the medications in this class. Follow current recommendations regarding preoperative management of patients who are taking GLP-1 receptor agonists which include holding medications, fasting, conducting an ultrasound to assess stomach contents, and in some cases, delaying surgery.
• Consult as needed. If GLP-1 receptor agonists are prescribed for Type 2 diabetes and are withheld for longer than the dosing schedule, consult with the provider who prescribed the medication regarding a strategy for bridging therapy to prevent hyperglycemia.
• Educate the patient. Discuss your plan for perioperative and postoperative management with the patient and answer their questions. Reinforce the education provided to patients by providing written instructions that they can take home for reference.
• Document. Thoroughly document your plan for preoperative management along with the education and counseling provided to the patient. Document the patient’s understanding of the information provided.
• Report adverse events. Report adverse events to your MPL insurance carrier, the U.S. Food and Drug Administration, and the manufacturer of the drug involved.

Copyrighted. No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.