What is the relationship between Glucagon-like peptide-1 (GLP-1) and anesthesia?

From the Guidelines

GLP-1 receptor agonists should be held on the day of surgery for patients undergoing anesthesia due to the increased risk of pulmonary aspiration associated with their use, as evidenced by recent studies 1. When considering the management of GLP-1 receptor agonists in the peri-operative period, it is essential to weigh the benefits of continued glycemic control against the potential risks of pulmonary aspiration. Recent evidence suggests that the use of GLP-1 receptor agonists is associated with an increased risk of retained gastric contents and pulmonary aspiration, even in patients who have fasted for an extended period 1.

• The study by Silveira et al. found that patients taking semaglutide had a significantly higher incidence of residual gastric content compared to those not taking the medication 1.
• Additionally, case reports have documented instances of regurgitation and pulmonary aspiration in patients taking GLP-1 receptor agonists, despite prolonged fasting times 1. In light of these findings, it is recommended that GLP-1 receptor agonists be held on the day of surgery to minimize the risk of pulmonary aspiration. However, the decision to hold or continue these medications should be made on a case-by-case basis, taking into account the individual patient's profile, the procedure, and the anaesthetic technique 1.
• For patients undergoing major surgeries or procedures requiring NPO status, holding the dose of GLP-1 receptor agonist may be necessary to reduce the risk of pulmonary aspiration.
• In contrast, for patients undergoing minor procedures or those with well-controlled diabetes, continuing the GLP-1 receptor agonist may be acceptable, provided that the patient is closely monitored for signs of pulmonary aspiration. Ultimately, the management of GLP-1 receptor agonists in the peri-operative period requires careful consideration of the potential benefits and risks, as well as close communication between the patient, anaesthesiologist, and other healthcare providers 1.

From the FDA Drug Label

Liraglutide injection delays gastric emptying [see Clinical Pharmacology (12. 2)]. There have been rare postmarketing reports of pulmonary aspiration in patients receiving GLP-1 receptor agonists undergoing elective surgeries or procedures requiring general anesthesia or deep sedation who had residual gastric contents despite reported adherence to preoperative fasting recommendations Available data are insufficient to inform recommendations to mitigate the risk of pulmonary aspiration during general anesthesia or deep sedation in patients taking liraglutide injection, including whether modifying preoperative fasting recommendations or temporarily discontinuing liraglutide injection could reduce the incidence of retained gastric contents Instruct patients to inform healthcare providers prior to any planned surgeries or procedures if they are taking liraglutide injection.

The use of GLP-1 receptor agonists, such as liraglutide, may increase the risk of pulmonary aspiration during general anesthesia or deep sedation due to delayed gastric emptying.

• Patients taking liraglutide injection should inform their healthcare providers before any planned surgeries or procedures.
• Available data are insufficient to provide recommendations on how to mitigate this risk, including whether modifying preoperative fasting recommendations or temporarily discontinuing liraglutide injection could reduce the incidence of retained gastric contents 2.

From the Research

GLP-1 and Anesthesia

• The relationship between GLP-1 and anesthesia is not directly addressed in the provided studies, which primarily focus on glucose monitoring and management in patients with diabetes undergoing surgery 3, 4, 5, 6.
• However, one study discusses the use of GLP-1 receptor agonists in the treatment of type 2 diabetes, highlighting their mechanisms of action, effectiveness, and potential benefits 7.
• GLP-1 receptor agonists have been shown to augment hyperglycemia-induced insulin secretion, suppress glucagon secretion, and reduce calorie intake and body weight 7.
• While there is no direct evidence on the interaction between GLP-1 and anesthesia, understanding the pharmacology and effects of GLP-1 receptor agonists may be relevant for anesthesiologists managing patients with diabetes undergoing surgery.

Perioperative Glucose Management

• Studies emphasize the importance of monitoring and managing blood glucose levels in patients with diabetes undergoing surgery to prevent complications 3, 4, 5, 6.
• Recommendations for perioperative glucose management include targeting blood glucose levels between 140-180 mg/dl and using rapid-acting insulin analogues or continuous intravenous insulin infusions as needed 4, 5.
• Anesthesiologists should be aware of the latest guidelines and evidence-based practices for managing blood glucose levels in patients with diabetes undergoing surgery.

GLP-1 Receptor Agonists in Diabetes Management

• GLP-1 receptor agonists are a well-established class of glucose-lowering agents with potential benefits for patients with type 2 diabetes, including weight reduction and cardiovascular risk reduction 7.
• These agents may be used in combination with other therapies, such as basal insulin, and are recommended as a preferred first injectable glucose-lowering therapy for type 2 diabetes 7.
• Further research is needed to fully understand the effects and potential applications of GLP-1 receptor agonists in diabetes management and other diseases.