GLP-1 receptor agonists and sedation for Ophthalmic surgery
Many of us are now aware of the reports of retained gastric contents in patients take glucagon-like peptide-1 (GLP-1) receptor agonists despite being appropriately NPO. These medications work by the inhibition of gastric emptying and stimulation of insulin production and reduction in glucagon secretion leading to lower insulin levels. The delayed gastric emptying reduces hunger, leading to a reduction in food intake and subsequent weight loss.
It is advisable to familiarize yourself with the generic and brand names of these medication and ensure that your preoperative staff is educated as well. There are various routes of administration such as oral pills and subcutaneous injections and administration could be daily or weekly. As of publication of this article, the current FDA approved GLP-1 medications are:
Dulaglutide (trulicity)
Exenatide (Bydureon, Byetta)
Semaglutide (Ozempic, Wegovy, Rybelsus)
Liraglutide (Victoza, Saxenda)
Lixisenatide (Adlyxin)
Tirzapatide (Mounjaro)
If the patient has GI symptoms such as nausea, vomiting, dyspepsia and abdominal distention, current evidence indicates there is an increased likelihood of retained gastric contents.2 Because of concerns over an increased risk of aspiration associated with GLP-1 agonists, the ASA Task Force on Preoperative Fasting reviewed the limited existing literature and compiled the following recommendations for elective procedures.3 This is taken directly from their statement which is linked in the references below.
“Day or week prior to the procedure:
· Hold GLP-1 agonists on the day of the procedure/surgery for patients who take the medication daily.
· Hold GLP-1 agonists a week prior to the procedure/surgery for patients who take the medication weekly.
· Consider consulting with an endocrinologist for guidance in patients who are taking GLP-1 agonists for diabetes management to help control their condition and prevent hyperglycemia (high blood sugar).
Day of the Procedure:
- · Consider delaying the procedure if the patient is experiencing GI symptoms such as severe nausea/vomiting/retching, abdominal bloating or abdominal pain and discuss the concerns of potential risk of regurgitation and aspiration with the proceduralist or surgeon and the patient.
- · Continue with the procedure if the patient has no GI symptoms and the GLP-1 agonist medications have been held as advised.
- · If the patient has no GI symptoms, but the GLP-1 agonist medications were not held, use precautions based on the assumption the patient has a “full stomach” or consider using ultrasound to evaluate the stomach contents. If the stomach is empty, proceed as usual. If the stomach is full or if the gastric ultrasound is inconclusive or not possible, consider delaying the procedure or proceed using full stomach precautions. Discuss the potential risk of regurgitation and aspiration of gastric contents with the proceduralist or surgeon and the patient.
- · Full stomach precautions should be used in patients who need urgent or emergency surgery.”
This is all well and good for general anesthetics, but what about procedures/surgery under light sedation such as cataract surgery? These medications are being prescribed in ever increasing amounts and not always by legitimate health care providers. Compounding pharmacies are now offering these medications as well as online websites. Further concerning is that patients may not disclose taking these medications as they don’t see it as a “medication.”
The Ophthalmic Anesthesia Society has received numerous inquiries as to what guidance, if any, we can provide. We recommend that patients be specifically asked if they are taking any GLP-1 medications, in what dose and delivery form, for what indication, and if they are having any GI side effects. Preferably this occurs at the surgeon’s office so that an intervention in dosing might be made. At the very least, sedation should be tailored to keep these patients as awake as possible. As sedation is a spectrum from light to deep, the final decision on how to proceed remains with the anesthesia provider and should be influenced by both patient and surgical factors. The OAS will continue to monitor the available evidence which will continue to evolve as more research is performed.
It is our expectation to perform a survey of our members regarding their anesthesia practices related to GLP-1 medications and present the data at our annual meeting. There will be a lecture and further discussion regarding this important subject. See you there!!
Vinodkumar Singh, MD FRCA MRCP
Professor
Department of Anesthesiology and Perioperative Medicine
Division of Critical Care Medicine
University of Alabama at Birmingham Hospital
619 S. 19th Street JT 804
Birmingham, AL 35249
References:
- Klein SR, Hobai IA. Semaglutide, delayed gastric emptying, and intraoperative pulmonary aspiration: A case report. Can J Anesth. 2023. DOI: 10.1007/s12630-023-02440-3.
- Silveira SQ, da Silva LM, Abib ACV et al. Relationship between perioperative semaglutide use and residual gastric content: A retrospective analysis of patients undergoing elective upper endoscopy. J Clin Anesth. 2023; 87: 111091.
- Powell K. Did you know that the ASA has offered guidance on preoperative management of patients on glucagon-like peptide-1 (GLP-1) receptor agonists for elective procedures? Online, August 2, 2023.
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