GLP-1 Receptor Agonists and Safety

A comprehensive clinical practice guidance document has been published online in the journal Surgery for Obesity and Related Diseases on October 29, addressing the safe use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) during the perioperative period. This multisociety effort aims to provide recommendations for healthcare providers managing patients on these medications in surgical settings.

Dr. Tammy L. Kindel from the Medical College of Wisconsin in Milwaukee, along with her colleagues, spearheaded the development of these guidelines. They acknowledge the transformative impact GLP-1 RAs have had on metabolic disease management while recognizing the need for specific perioperative protocols.

The guidance emphasizes a collaborative approach, encouraging shared decision-making between patients and their care teams, including procedural, anesthesia, and prescribing specialists. This process should weigh the metabolic benefits of continuing GLP-1 RA therapy against potential surgical risks.

A key focus of the recommendations is the assessment of factors that may increase the risk of delayed gastric emptying and aspiration. The document stresses the importance of conducting these evaluations well in advance of scheduled surgeries to allow for necessary adjustments in perioperative care plans.

To mitigate the risk of aspiration associated with delayed gastric emptying, the guidance suggests implementing preoperative dietary modifications and considering alterations to anesthesia protocols. Specifically, for cases where delayed gastric emptying is a concern, the document recommends a liquid diet for at least 24 hours prior to the procedure.

The authors clarify that this document should be interpreted as clinical guidance rather than a definitive, evidence-based guideline. Its primary aim is to facilitate decision-making processes that balance safety considerations with the therapeutic needs of patients taking GLP-1 RAs who require surgical or procedural interventions.

It’s worth noting that several authors involved in developing these recommendations have disclosed financial relationships with pharmaceutical and medical device industries.

Commentary by YourDailyFit columnist Alice Winters:

The release of these guidelines marks a crucial step in addressing the growing intersection of metabolic health management and surgical care. As GLP-1 receptor agonists like semaglutide (Ozempic, Wegovy) and tirzepatide (Mounjaro) continue to dominate headlines and transform patient care, their impact extends far beyond the realm of endocrinology and primary care.

This guidance document astutely recognizes the double-edged sword that GLP-1 RAs represent in the perioperative setting. On one hand, these medications offer unprecedented glycemic control and weight loss benefits, potentially reducing surgical risks associated with obesity and diabetes. On the other, their mechanism of action – particularly the slowing of gastric emptying – poses unique challenges in the context of anesthesia and surgical recovery.

The emphasis on shared decision-making is commendable, acknowledging the complexity of these cases and the need for individualized care plans. However, this approach also highlights the urgent need for more robust, evidence-based protocols. The current reliance on clinical judgment, while necessary, underscores the relative novelty of widespread GLP-1 RA use and the gaps in our understanding of their perioperative implications.

The recommendation for preoperative dietary modification is a practical, if somewhat conservative, approach to mitigating aspiration risk. A 24-hour liquid diet is a small price to pay for enhanced surgical safety, but it raises questions about the potential for more targeted interventions. Future research might explore whether the duration of this dietary modification could be tailored based on the specific GLP-1 RA used, its dosage, and individual patient factors.

It’s noteworthy that the guidance stops short of recommending universal discontinuation of GLP-1 RAs prior to surgery. This nuanced stance reflects an understanding of the metabolic benefits these drugs provide, particularly for patients with poorly controlled diabetes or severe obesity. However, it also places a significant burden on surgical teams to carefully assess and manage these patients.

The disclosure of industry ties among some authors is a double-edged sword. While it ensures that the guidance benefits from deep, practical knowledge of these medications, it also necessitates careful scrutiny to ensure that recommendations are not unduly influenced by commercial interests.

In conclusion, this guidance document represents a critical first step in navigating the complex interplay between GLP-1 RAs and perioperative care. As our experience with these medications grows, we can anticipate more refined, evidence-based protocols emerging. For now, clinicians and patients alike must engage in careful dialogue, weighing the substantial benefits of these revolutionary drugs against the nuanced risks they may pose in surgical settings. The era of personalized medicine is upon us, and nowhere is this more evident than in the management of patients on GLP-1 RAs undergoing surgery.