What are the guidelines for discontinuing Glucagon-like peptide-1 (GLP-1) receptor agonists, such as exenatide (Byetta), liraglutide (Victoza), and dulaglutide (Trulicity), before procedures with Monitored Anesthesia Care (MAC) sedation and local anesthetic?

Guidelines for Discontinuing GLP-1 Medications Before Procedures with MAC Sedation and Local Anesthetic

For patients taking GLP-1 receptor agonists, these medications should be held for at least three half-lives before procedures with MAC sedation and local anesthetic to reduce the risk of pulmonary aspiration. 1

Recommendations Based on Indication for GLP-1 Use

For Weight Loss Patients

• Hold GLP-1 receptor agonists for at least three half-lives before the procedure (approximately 88% drug clearance) 1
• Examples of discontinuation timing:
  • Semaglutide (Wegovy/Ozempic): Hold for 3 weeks (7-day half-life) 1
  • Dulaglutide (Trulicity): Hold for 2 weeks (4.5-4.7 day half-life) 1
  • Liraglutide (Victoza/Saxenda): Hold for 39 hours (13-hour half-life) 1
  • Exenatide (Byetta): Hold for 7.2 hours (2.4-hour half-life) 1

For Type 2 Diabetes Patients

• Consult with the treating endocrinologist regarding: 1
  • Risks and benefits of holding the drug for at least three half-lives 1
  • Recommendations for bridging diabetic therapy if the GLP-1 receptor agonist will be held longer than the next scheduled dosing time 1
• Consider the potential benefits of GLP-1 RAs in the perioperative period (improved glycemic control, reduced cardiovascular events) against the risk of delayed gastric emptying 1

Risk Assessment and Management

High-Risk Patients Requiring Additional Precautions

• Patients unable to hold the GLP-1 receptor agonist for three half-lives 1
• Those who have recently started the medication or increased their dose 1
• Patients experiencing nausea, vomiting, or abdominal distention 1
• Those taking other medications that delay gastric emptying (opioids, PPIs, TCAs) 1
• Recent intake of recreational drugs that delay gastric emptying (alcohol, cannabis) 1
• History of gastro-esophageal surgery 1

Day of Procedure Management

• For high-risk patients or those who couldn't discontinue GLP-1 RAs for three half-lives: 1
  • Consider prokinetic drugs (metoclopramide or erythromycin) pre-operatively 1
  • Use point-of-care gastric ultrasound to assess residual gastric contents 1
  • If gastric volume >1.5 ml/kg or solid contents are present, consider delaying the procedure 1
  • Consider rapid sequence intubation if proceeding with general anesthesia 1

Documentation and Communication

• Document the following information for all patients on GLP-1 receptor agonists: 1
  • Indication and dose of GLP-1 receptor agonist 1
  • Date medication was commenced, dose variations, last dose taken 1
  • Symptoms of nausea, vomiting or abdominal distention 1
  • Co-prescribed drugs that can delay gastric emptying 1
• Instruct patients to inform healthcare providers prior to any planned surgeries or procedures if they are taking GLP-1 receptor agonists 2
• Use a shared decision-making approach with patients to discuss risks and benefits 1

Special Considerations for MAC Sedation

• Even with MAC sedation and local anesthetic, the risk of pulmonary aspiration remains due to delayed gastric emptying 1, 2
• The FDA label for liraglutide specifically mentions pulmonary aspiration risk during general anesthesia or deep sedation 2
• Multiple case reports document aspiration events despite extended fasting periods in patients on GLP-1 RAs 1
• Standard fasting guidelines may be insufficient for patients on GLP-1 RAs 1

Caveats and Pitfalls

• Discontinuation of long-acting GLP-1 RAs for 7 days may not be sufficient to ensure an empty stomach pre-operatively 1
• Tachyphylaxis to the gastric emptying effects of GLP-1 RAs may develop after >12 weeks of use, but this doesn't eliminate the risk 1
• There is currently limited high-quality evidence on the optimal discontinuation period for GLP-1 RAs 1, 3
• The risk-benefit assessment differs between patients using GLP-1 RAs for weight loss versus diabetes management 1