From the Guidelines
When holding GLP-1 receptor agonists for surgery, basal insulin such as insulin glargine (Lantus) at 0.2-0.3 units/kg/day or insulin detemir (Levemir) at similar doses should be used to maintain glycemic control, as recommended by the most recent guidelines 1.
Perioperative Management
The management of patients on GLP-1 receptor agonists undergoing surgery requires careful consideration of the risks and benefits of holding the medication, as well as alternative strategies for maintaining glycemic control.
- The decision to hold GLP-1 receptor agonists should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history.
- For patients with type 2 diabetes, basal insulin such as insulin glargine (Lantus) at 0.2-0.3 units/kg/day or insulin detemir (Levemir) at similar doses can be used to maintain glycemic control 1.
- For those requiring more intensive control, a basal-bolus regimen may be needed, adding rapid-acting insulin like insulin lispro (Humalog) or insulin aspart (NovoLog) at 0.05-0.1 units/kg per meal.
- GLP-1 medications should generally be held 24 hours before major surgery for short-acting formulations and up to a week for long-acting weekly preparations, as suggested by recent studies 1.
Monitoring and Target Range
During the perioperative period, blood glucose should be monitored every 4-6 hours, with a target range of 140-180 mg/dL, to minimize the risk of hyperglycemia and its associated complications 1.
- This approach is necessary because GLP-1 agonists can affect gastric emptying and may increase the risk of aspiration during anesthesia, while insulin provides reliable glucose control during the metabolic stress of surgery.
- The use of prokinetic drugs such as metoclopramide or erythromycin pre-operatively may also be considered to reduce the risk of aspiration 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Medication Options When Holding GLP-1 for Surgery
- There is limited evidence to support a specific medication to use when holding GLP-1 for surgery 2.
- However, studies suggest that discontinuing GLP-1 RA treatment may worsen glycemic control in patients with diabetes, and an alternative multidisciplinary approach to manage patients undergoing elective surgery may be necessary 2.
- Insulin degludec and insulin aspart are novel insulins that can be used for the management of diabetes mellitus, but their use in the context of holding GLP-1 for surgery is not specifically addressed in the available evidence 3.
Considerations for Peri-Operative Care
- GLP-1R agonists are known for their effects of glucose-lowering and gastroparesis, which may cause safety concerns regarding induction of anesthesia, specifically the risk of pulmonary aspiration 4.
- However, current evidence suggests that there is no increased risk of pulmonary aspiration, and future perspectives should focus on the actual risk of pulmonary aspiration and the possible implementation of ultrasound in the preoperative assessment 4.
Impact of GLP-1 Receptor Agonist Therapy
- GLP-1 RA can result in significant loss of lean body mass, which may place certain patient populations at higher risk for muscle loss and adverse events 5.
- A targeted and individualized nutrition and physical activity regimen should be instituted for each patient to minimize loss of muscle mass while promoting the loss of fat mass 5.