What is the management of a ligament rupture in a patient taking GLP-1 (Glucagon-like peptide-1) receptor agonists, such as exenatide (Byetta) or liraglutide (Victoza)?

Management of Ligament Rupture in Patients on GLP-1 Receptor Agonists

For patients with ligament rupture who are taking GLP-1 receptor agonists, the medication should be held for at least three half-lives before any surgical intervention to minimize the risk of pulmonary aspiration during anesthesia. 1

Pre-Surgical Considerations

Medication Management

• For once-weekly GLP-1 RAs (semaglutide, dulaglutide, exenatide extended-release):

  • Hold for 3 weeks before elective surgical repair
  • This allows for clearance of approximately 88% of the drug 1, 2

• For once-daily GLP-1 RAs (liraglutide, lixisenatide):

  • Hold for 3-4 days before surgical repair
  • For liraglutide specifically, consider reducing by 0.6 mg increments every 2 days before complete cessation 2

• For twice-daily GLP-1 RAs (exenatide):

  • Hold for 2-3 days before surgical repair 1

Risk Assessment

When evaluating a patient with ligament rupture on GLP-1 RA therapy, consider:

1. Indication for GLP-1 RA use:

   • Diabetes management: Consult with endocrinologist regarding alternative glycemic control during perioperative period 1
   • Weight management only: Temporary discontinuation presents lower risk 1

2. Duration of GLP-1 RA therapy:

   • Recently initiated or dose escalated: Higher risk of delayed gastric emptying 1
   • Long-term stable dose: Some tachyphylaxis may occur, but risk remains 1

3. Symptoms of GI effects:

   • Presence of nausea, vomiting, or abdominal distention increases aspiration risk 1

Surgical Management

For Emergency Surgery (Cannot Wait for Drug Clearance)

1. Implement aspiration risk reduction strategies:

   • Consider prokinetic agents (metoclopramide) preoperatively 1
   • Use point-of-care gastric ultrasound to assess residual gastric contents 1
   • Employ rapid sequence intubation technique 1
   • Consider pre-emptive gastric decompression in high-risk cases 1

2. Anesthesia considerations:

   • Inform anesthesiologist about GLP-1 RA use and timing of last dose 1
   • Document drug type, dose, and last administration time 1

For Elective Surgery

1. Optimal timing:

   • Schedule surgery after appropriate drug clearance period (3 half-lives) 1, 2
   • Consider longer fasting periods than standard protocols 1

2. Bridging therapy for diabetic patients:

   • Consult endocrinology for alternative glucose management during GLP-1 RA pause 1
   • Monitor glucose levels closely during perioperative period 1

Post-Surgical Management

Resumption of GLP-1 RA Therapy

• For weight management indication:

  • Resume at lower dose 1-2 weeks post-surgery when normal oral intake is established 2
  • Gradually titrate back to therapeutic dose 2

• For diabetes management indication:

  • Resume at lower dose when oral intake is established 1
  • Consider temporary insulin therapy if needed for glycemic control 1

Rehabilitation Considerations

• Monitor for potential impacts on healing:
  • GLP-1 RAs do not appear to directly impact ligament healing based on available evidence
  • Focus on standard rehabilitation protocols for ligament rupture

Common Pitfalls and Caveats

• Failure to recognize aspiration risk: Despite prolonged fasting, patients on GLP-1 RAs may still have delayed gastric emptying and increased risk of aspiration during anesthesia 1

• Inadequate communication: Ensure all members of the surgical team are aware of the patient's GLP-1 RA use and the associated risks 1

• Rapid resumption post-surgery: Restarting GLP-1 RAs too quickly post-surgery may increase nausea and vomiting, potentially complicating recovery 2

• Glycemic control issues: For diabetic patients, have a clear plan for alternative glycemic management during the perioperative period when GLP-1 RAs are held 1