With the rapid growth of patients taking glucagon-like peptide-1 receptor agonists (GLP-1), anesthesia professionals and surgical teams are dealing with the quandary of whether to hold or not hold these medications prior to an anesthetic and surgical procedure.
GLP-1 medications such as Ozempic or Wegovy are prescribed to diabetic patients for glucose control and have become popular in promoting weight loss. However, since the rapid, ongoing growth in prescribing these medications, little research has been done on whether it is safe to continue the medication prior to an anesthetic or should it be withheld for a defined period of time.
These medications are known for their appetite suppression leading to weight loss. Patients experience feeling full despite varying periods of food abstinence. GLP-1 medications slow gastric emptying, leading to the potential of a full stomach during anesthesia, resulting in vomiting and food aspiration. Anesthesia professionals and surgical teams must collaborate to minimize the risk of complications during a procedure. With limited data for recommended guidelines, professional associations and societies are releasing clinical practice updates and considerations for safe patient care.
The American Society of Anesthesiologists (ASA) initially suggested patients taking GLP-1 medications should stop before elective surgery. ASA consensus-based guidance of preoperative management of patients on GLP-1, published in June 2023, recommends that patients on daily dosing consider holding GLP-1 agonists on the day of the procedure. And, that patients on weekly dosing consider holding GLP-1 agonists a week prior to a procedure. This suggestion is irrespective of the indication (type 2 diabetes or weight loss) or type of procedure/surgery. Consideration should be given to diabetes management and glucose control if medication is held for longer than the dosing schedule to avoid hyperglycemia.
The American Association of Nurse Anesthesiology (AANA) published considerations for anesthesia care of the patient on a GLP-1 to aid anesthesia professionals in developing facility policies and procedures that align with the best evidence on treating patient taking GLP-1 medications. The consideration document states, “The length of time various GLP-1 medications continue to impact a patient were considered in developing these recommendations. If daily dose of GLP-1 medication is taken, consider holding the medication the day of surgery/ procedure. If weekly dose, consider holding the medication for one week before the surgery/procedure.” Additionally, the AANA has developed a document, Anesthesia Care of the Patient on a GLP-1 Receptor Agonist, to educate its members on anesthesia care.
The American Gastroenterological Association (AGA) released a clinical practice update and found insufficient data to support patients stopping GLP-1 medication prior to elective endoscopy procedures. For individuals with severe gastroparesis scheduled for endoscopy, many gastroenterologists advise to maintain a clear liquid diet the day before the procedure, excluding solid food. This advice may be extended to patients on GLP-1 receptor agonists as well. Given the long half-life of these medications, the AGA does not support the premise that holding these medications for one week prior to the procedure will adequately prevent aspiration of any retained gastric contents due to GLP-1 slowing of stomach emptying. Rather, the AGA recommends that patients be on a liquid diet for one day prior to any endoscopic procedure if they are on a GLP-1 medicine.
In a recently published article in MedPage Today referencing a study published in JAMA Surgery, One-Week GLP-1 Agonist Hold Not Enough Before Anesthesia?, 124 patients undergoing an elective procedure requiring anesthesia, the prevalence of increased residual gastric content was 56% for those taking GLP-1 agonists compared with 19% for those without use of these drugs, reported Sudipta Sen, MD.” Dr. Sen’s group concluded with, “Future studies are needed to determine more specific safe discontinuation intervals and preprocedural fasting times for these agents prior to elective procedures under anesthesia. A simplistic approach of holding the GLP-1 RA for longer intervals (3-5 weeks) may not be tenable, especially when prescribed for glycemic control. However, this may be a viable strategy for GLP-1 RA use in weight management.”
Jay Horowitz, APRN, CRNA, states, “It is imperative to stay on top of new technologies and medication to ensure patient safety and provide optimal care.” He has published articles in Outpatient Surgery Magazine sharing his experience as an anesthesia clinical leader working in two fast-paced, progressive, single-specialty (Ophthalmology) ASCs providing local with sedation anesthesia. Initially, in 2022, he conducted an in-house study looking at pre- and post-op glucose levels in patients taking typical Type 1 and Type 2 Diabetes medications to determine for his patient population, procedures, and type of anesthesia care a practice guideline for patient management with diabetes. In a follow-up study, he looked at the effect on glucose pre- and post-op for patients taking only GLP-1 medications, whether for Type 2 diabetes or weight loss. The study was aimed at evaluating whether these patients should be treated like patients on non-GLP-1 diabetic medication or whether they are different and do not require D5W to prevent post-op hypoglycemia. The results led his team to continue checking glucose levels pre- and post-op but not administering IV D5W unless the patient presents with a blood glucose level below 70. This policy led to cost savings, decreased staff workload, and greater efficiency.
Whether GLP-1 medications are held prior to surgery or not, due to the risk of complications, the anesthesia professional may need to do additional screening prior to induction of anesthesia. One option is to ultrasound a patient’s stomach before surgery, and if gastric contents are present, consider delaying an elective procedure or proceeding as if the patient has a full stomach to reduce the risk of aspiration.
The professional associations, societies, and current literature agree that an individualized approach should be taken to managing patients on GLP-1 medications. Additionally, more investigation and scientific study is required to determine the correct protocols for best practices, safety, and optimal outcomes. It is imperative for patients to disclose the use of these medications to their healthcare team. It is imperative for surgical teams and anesthesia professionals to review their facility’s policies and procedure recommendations to provide optimal, safe care to their patients.
Several QUAD A surgical and procedural Standards relate to this directive. Standard 9A1 states, “The facility has a governing body with full legal responsibility for determining, implementing, and monitoring policies governing facility’s total operation. The governing body has oversight and accountability for the quality assessment and performance improvement program, ensures that the facility policies and programs are administered so as to provide quality health care in a safe environment, and develops and maintains a disaster preparedness plan.” Furthermore, Standard 8B24 states, “The surgeon/proceduralist and the licensed or qualified anesthesia provider concur on the appropriateness of the procedures performed at the facility based on the medical status of the patient, age and physiological appropriateness of the patient, and qualification of the providers and the facility resources.” Additionally, Standard 1C1 states, “A patient who, by reason of pre-existing or other medical conditions, is at significant risk for outpatient surgery in this facility should be referred to alternative facilities.” As a result of the discussion, QUAD A recommends facilities develop a policy including criteria to determine the best course of action for patients taking GLP-1 medications for glucose control or weight loss.Since 1980, QUAD A (a non-profit, physician founded and led global accreditation organization) has worked with thousands of healthcare facilities to standardize and improve the quality of health care they provide – believing that patient safety should always come first. To learn more about QUAD A, their accreditation process, and why it’s so important to seek out accredited facilities when making healthcare related decisions, visit www.quada.org.