Can GLP-1 (Glucagon-like peptide-1) receptor agonists be taken perioperatively?

From the Guidelines

GLP-1 receptor agonists should be held for at least three half-lives ahead of the procedure to minimize the risk of gastric stasis and aspiration or regurgitation in the perioperative period, as recommended by the most recent study 1. When considering the management of GLP-1 receptor agonists in the perioperative period, several factors must be taken into account, including the risk of delayed gastric emptying, hypoglycemia, and nausea and vomiting.

• The primary concern is the increased risk of gastric stasis and aspiration or regurgitation associated with the use of GLP-1 receptor agonists, as highlighted in a recent narrative review 2.
• The current evidence suggests that holding GLP-1 receptor agonists for at least three half-lives before the procedure can help mitigate this risk, as recommended by a recent study 3.
• However, the decision to hold or continue GLP-1 receptor agonists should be individualized, taking into account the patient's specific circumstances, including the type of surgery, diabetes control, and other medical conditions, as emphasized in a recent review 4.
• It is also important to consider the potential impact of holding GLP-1 receptor agonists on perioperative glycemic control, as noted in a recent guideline 5.
• Ultimately, the specific timing for stopping and restarting GLP-1 receptor agonists should be determined by the healthcare provider, based on the patient's individual needs and circumstances, as recommended by the most recent study 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, perioperatively is associated with a risk of pulmonary aspiration due to delayed gastric emptying. However, the available data are insufficient to provide clear recommendations on how to mitigate this risk, including whether to temporarily discontinue liraglutide injection or modify preoperative fasting recommendations 6. As a result, caution should be exercised when using liraglutide injection in patients undergoing surgery, and patients should be instructed to inform their healthcare providers prior to any planned surgeries or procedures. Key considerations include:

• Delayed gastric emptying
• Risk of pulmonary aspiration
• Insufficient data to inform mitigation strategies
• Need for caution and patient education 6

From the Research

Perioperative Use of GLP-1 Receptor Agonists

• The American Society of Anesthesiologists (ASA) Task Force has recommended discontinuing glucagon-like peptide-1 receptor agonist (GLP-1 RA) agents before surgery due to the potential risk of pulmonary aspiration 7.
• However, there is limited scientific evidence to support this recommendation, and holding GLP-1 RA treatment may worsen glycemic control in patients with diabetes 7.
• A multidisciplinary approach to manage patients undergoing elective surgery is suggested, as well as the need for well-conducted observational and prospective studies to determine the risk of pulmonary aspiration in persons receiving GLP-1 RA 7.

Mechanisms and Effects of GLP-1 Receptor Agonists

• GLP-1 receptor agonists have several mechanisms of action, including augmentation of hyperglycemia-induced insulin secretion, suppression of glucagon secretion, deceleration of gastric emptying, and reduction in calorie intake and body weight 8.
• GLP-1 RAs can be injected twice daily, once daily, or once weekly, and have been shown to be effective in lowering A1C and weight, with a low risk of hypoglycemia 8, 9.
• The gastrointestinal effects of GLP-1 RAs, including delayed gastric emptying, may increase the risk of aspiration at the time of surgery or upper gastrointestinal endoscopy 10.

Clinical Considerations

• The selection of the most appropriate GLP-1 RA treatment for individual patients is important, taking into account factors such as efficacy, safety, and dosing frequency 9, 11.
• Head-to-head clinical studies have demonstrated that all GLP-1 RA agents are effective therapeutic options at reducing A1C, but differences exist in terms of magnitude of effect on A1C and weight, as well as frequency of adverse effects 11.