Safe Use of Glucagon-like Peptide-1 Receptor Agonists in the Perioperative Period

• Care teams should consider the following variables as elevating the risk of delayed gastric emptying and aspiration with the periprocedural use of GLP-1RA:
  • Escalation phase: The escalation phase, versus the maintenance phase, is associated with a higher risk of delayed gastric emptying with GLP-1RA usage.
  • Higher dose: The higher the dose of GLP-1RA, the more likely the risk of gastrointestinal side effects.
  • Weekly dosing: Gastrointestinal side effects are more common with weekly compared to daily formulation compounds.
  • Presence of gastrointestinal symptoms: Symptoms suggestive of delayed gastric emptying and intestinal transit times may include nausea, vomiting, abdominal pain, dyspepsia, and constipation.
  • Medical conditions beyond GLP-1RA usage which may also delay gastric emptying: Patients on GLP-1RA should be evaluated for other medical conditions which may exacerbate gastrointestinal symptoms and delay gastric emptying, such as but not limited to bowel dysmotility, gastroparesis, and Parkinson’s disease.

The assessment for these risk factors should occur with enough advance time prior to surgery to allow adjustments in preoperative care if indicated, including diet modification and evaluation of the feasibility of medication bridging if GLP-1RA discontinuation is indicated.

• GLP-1RA therapy may be continued preoperatively in patients without elevated risk of delayed gastric emptying and aspiration based on Recommendation 1a. When an elevated risk of delayed gastric emptying and aspiration exist, withholding of GLP-1RAs should be balanced with the surgical and medical risk of inducing the potential for a hazardous, metabolic disease state, like hyperglycemia. Further, bridging therapy off a GLP-1RA may be resource-intensive, cost or insurance prohibitive, and risk other adverse side effects like hypoglycemia. Finally, withholding GLP-1RA perioperatively only for patients with the diseases of overweight and obesity, without an indication as described in Recommendation 1a, could constitute overweight and obesity bias, which should be avoided.
• If the decision to hold GLP-1RAs is indicated given an unacceptable safety profile following shared decision-making in the preoperative period, the duration to hold therapy is unknown [7]. At this time, it is suggested to follow the original guidance of the American Society of Anesthesiologists, holding the day of surgery for daily formulations, and a week prior to surgery for weekly formulations [4]. All patients should still be assessed on the day of procedure for symptoms suggestive of delayed gastric emptying.

• Preoperative diet modification (preoperative liquid diet for at least 24 hours, as performed in patients undergoing colonoscopy and bariatric surgery) can be utilized in patients when there is concern for delayed gastric emptying based on clinical symptom review as described in Recommendation 1.
• When clinical concern for retained gastric contents exists on the day of the procedure, point-of-care gastric ultrasound could be used to assess aspiration risk. This technology may be clinically limited based on institutional resources, interuser variability, and credentialing requirements.
• When clinical concern for retained gastric contents exists or is confirmed on the day of the procedure, providers should engage patients in a shared decision-making model and consider the benefits and risks of rapid sequence induction of general anesthesia for tracheal intubation to minimize aspiration risk versus procedure cancellation.

Safe continuation of surgery and gastrointestinal endoscopy, and prevention of procedure cancellation, for patients on GLP-1RAs can be prioritized following the recommendations above, as would occur for other patient populations with gastroparesis.