From the Guidelines
Rybelsus (semaglutide) should be held at least 3 weeks before surgery for patients taking it for weight loss, and at least 1 week before surgery for patients with diabetes mellitus, due to its effects on gastric emptying and the risk of pulmonary aspiration. The decision to hold Rybelsus before surgery is based on its pharmacological properties as a GLP-1 receptor agonist, which slows gastric emptying and may increase the risk of aspiration during anesthesia 1.
Key Considerations
- The medication's half-life and the patient's individual circumstances, such as the type of surgery and underlying medical conditions, should be taken into account when making this decision.
- For patients with diabetes mellitus, the benefits of continuing GLP-1 receptor agonists in the peri-operative period may outweigh the risks, as they can help maintain glycemic control and reduce the risk of postoperative major adverse cardiac events 1.
- However, for patients taking GLP-1 receptor agonists for weight loss, the risks may outweigh the benefits, and cessation of the medication for at least three half-lives before the procedure may be recommended to minimize the risk of gastric stasis and pulmonary aspiration 1.
Perioperative Management
- Patients should discuss their medication management with both their surgeon and the physician who prescribed Rybelsus to determine the best course of action for their individual situation.
- After surgery, Rybelsus can typically be restarted once the patient has resumed normal oral intake and is clinically stable, but specific timing should be determined by the healthcare team.
- The American College of Cardiology/American Heart Association joint committee on clinical practice guidelines recommends that weekly formulations of GLP-1 agonists be held >1 week before elective noncardiac surgery for weekly dosed GLP-1 agonists and the day before for daily dosed GLP-1 agonists to reduce the risk of pulmonary aspiration of gastric contents at the time of surgery 1.
From the Research
Perioperative Management of Semaglutide
The question of whether Rybelsus (semaglutide) needs to be held prior to surgery can be informed by several studies:
- A retrospective analysis 2 found that semaglutide use was associated with increased residual gastric content (RGC) in patients undergoing elective upper endoscopy.
- A prospective observational study 3 found that pre-operative semaglutide use within 10 days of elective surgical procedures was independently associated with increased risk of residual gastric content on pre-operative gastric ultrasound assessment.
- A case report 4 highlighted the importance of considering delayed gastric emptying in patients taking semaglutide, as it may increase the risk of intraoperative pulmonary aspiration.
Key Findings
Key findings from these studies include:
- Semaglutide use is associated with increased RGC in patients undergoing elective procedures 2, 3.
- The risk of increased RGC is higher in patients taking semaglutide, even after adequate preoperative fasting 2, 3.
- Delayed gastric emptying is a known side effect of semaglutide, which may increase the risk of intraoperative pulmonary aspiration 4.
Implications for Perioperative Management
These findings have implications for the perioperative management of patients taking semaglutide:
- Anesthesiologists should be aware of the potential for delayed gastric emptying and increased RGC in patients taking semaglutide 4.
- Patients taking semaglutide may require alternative methods to ensure no food is present in the stomach before undergoing general anesthesia 4.
- The decision to hold semaglutide before surgery should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history.