Is gastric sleeve surgery a contraindication for Glucagon-like peptide-1 (GLP-1) receptor agonists?

GLP-1 Receptor Agonists After Gastric Sleeve Surgery: Perioperative Considerations

Gastric sleeve surgery is not a contraindication for GLP-1 receptor agonists, but special perioperative management is required due to the increased risk of aspiration from delayed gastric emptying. 1, 2

Risk Assessment for Patients with Previous Gastric Sleeve

• GLP-1 receptor agonists significantly delay gastric emptying, increasing the risk of regurgitation and pulmonary aspiration during procedures requiring sedation or anesthesia 1
• Previous gastro-oesophageal surgery, including gastric sleeve, is specifically listed as a risk factor that should be documented when assessing patients on GLP-1 agonists 1
• Multiple case reports document regurgitation and pulmonary aspiration in patients on GLP-1 agonists despite appropriate fasting periods, highlighting the need for caution in all surgical patients 1

Management Recommendations for Perioperative Period

Preoperative Considerations

• Hold GLP-1 receptor agonists for at least three half-lives before any elective procedure to clear approximately 88% of the drug 1
• For patients taking GLP-1 receptor agonists for weight loss after gastric sleeve surgery, holding for three half-lives is strongly recommended 1
• For patients with diabetes taking GLP-1 receptor agonists, consult with an endocrinologist regarding:
  • Risks and benefits of holding the medication for three half-lives 1
  • Recommendations for bridging diabetic therapy if the GLP-1 receptor agonist needs to be held longer than the next scheduled dose 1

Risk Mitigation Strategies

For patients who cannot hold GLP-1 receptor agonists for three half-lives or who have recently started/increased their dose:

• Consider prokinetic drugs such as metoclopramide or erythromycin pre-operatively 1, 2
• Use point-of-care gastric ultrasound to assess residual gastric contents 1
• Consider rapid sequence intubation to reduce aspiration risk 1
• In very high-risk patients, pre-emptive gastric decompression may be considered 1

Special Considerations for Post-Sleeve Gastrectomy Patients

• Patients with previous sleeve gastrectomy may have altered GLP-1 physiology, as sleeve gastrectomy itself increases endogenous GLP-1 levels 3
• GLP-1 receptor agonists are increasingly used to manage weight regain after sleeve gastrectomy 4, 3
• Patients with sleeve gastrectomy may have a higher risk of postoperative nausea and vomiting when exposed to GLP-1 receptor agonists 5

Clinical Decision Algorithm

1. Document:

   • Indication and dose of GLP-1 receptor agonist 1
   • Date drug commenced, dose variations, last dose taken 1
   • Symptoms of nausea, vomiting or abdominal distention 1
   • Details of gastric sleeve surgery (when performed, any complications) 1

2. Determine appropriate holding period based on specific GLP-1 agent:

   • Weekly semaglutide: 21 days (half-life of 7 days × 3) 2
   • Weekly dulaglutide: 14 days (half-life of 4.5-4.7 days × 3) 2
   • Daily liraglutide: 39 hours (half-life of 13 hours × 3) 2

3. Risk stratification:

   • High risk: Unable to hold medication for three half-lives, recently started medication, experiencing GI symptoms 1, 6
   • Lower risk: Medication held for appropriate time, on stable dose for >12 weeks 6

4. For high-risk patients:

   • Consider postponing elective procedures 1
   • Implement aspiration risk reduction strategies 1, 2
   • Use gastric ultrasonography to guide decision-making 1

Common Pitfalls and Caveats

• Relying solely on standard fasting guidelines is insufficient for patients on GLP-1 agonists, as case reports show aspiration despite extended fasting periods 1, 2
• Assuming that patients with gastric sleeve have normal gastric emptying is incorrect - the combination of sleeve gastrectomy and GLP-1 agonists may have synergistic effects on gastric motility 3
• Underestimating the aspiration risk with "light" sedation is dangerous, as even minimal sedation can impair protective reflexes 2
• The American Society of Anesthesiologists and American Gastroenterological Association have different recommendations, with the latter advocating for a more individualized approach 7