Reference: ASA 2023 Jun 29
Practice Point: Consider holding the last dose of GLP-1 receptor agonists prior to elective surgery to reduce aspiration risk.
EBM Pearl: While case reports definitely don’t prove effectiveness of an intervention, they can be an important source of early safety signals.
Clinicians who do preoperative visits are well-versed in telling patients to stop NSAIDs 7 days before a procedure and to stop warfarin 5 days before a procedure, and they have hopefully gotten the memo that you don’t touch beta-blockers anymore. However, guidance from the American Society of Anesthesiologists (ASA) recommends holding the last dose of any GLP-1 receptor agonists (like semaglutide) prior to elective surgery to avoid the risk of aspiration. Practically speaking, this means holding a weekly-dosed agent for 1 week prior to surgery and holding a daily-dosed agent 1 day prior to surgery.
GLP-1 agonists are well known to cause gastrointestinal upset, including nausea, vomiting, and delayed gastric emptying, especially shortly after initiation or dose increases. Even small amounts of regurgitated gastric contents can increase the risk of perioperative complications, mainly pulmonary aspiration. If it hadn’t crossed your mind yet to tell patients to hold GLP-1 agonists prior to surgery, you’re in luck: You were following older guidelines that suggested there was no need to withhold these drugs. However, the new consensus-based guidance from the ASA says otherwise.
Making sense of conflicting guidance can be tough. From an EBM perspective, in addition to the evidence, there are philosophical biases and conflicts to consider. Our first question is usually whether or to what extent the group evaluated available evidence to inform their recommendations. In this case, we actually wondered if there was any evidence to consider at all.
We dug deeper and confirmed that the ASA’s recommendation to hold GLP-1 agonists is related to a risk of delayed gastric emptying resulting in retained stomach contents, regurgitation, or pulmonary aspiration. A recent review article described that the evidence is derived from case reports, which is an important type of literature to highlight early safety signals. However, less clear from this (low-quality) evidence is exactly how long to hold GLP-1 agonists. There is a lot of controversy over how dangerous this risk is but not a lot of high quality evidence. We are not impressed with retrospective cohort studies which fail to even ascertain if the medications have been held prior to surgery.
When it comes to preoperative management of patients taking GLP-1 agonists, an individualized approach is probably the way to go for now, with most weight given to first doing no harm (or doing the least harm). For example, you probably do want to hold GLP-1 agonists for patients with a recent initiation or dose increase who are more likely to be in the throes of gastrointestinal side effects. Likewise, if they have well-controlled diabetes and are on other diabetes medications that will help maintain blood glucose control, it seems smartest to stop GLP-1 agonists for them as well because the relative risk of hyperglycemia would presumably be low. But for some people with poorly controlled diabetes, perioperative hyperglycemia may carry its own risks. Until we have better data, the decision whether to hold GLP-1 agonists or not seems to primarily come down to balancing the estimated risk of hyperglycemia if you stop them versus the risk of aspiration if you don’t stop them. For most people, but not everyone, they should be held.
For more information, see the topic Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists for Adults With Diabetes Mellitus in DynaMed.
DynaMed EBM Focus Editorial Team
This EBM Focus was written by McKenzie Ferguson, PharmD, BCPS, Senior Clinical Writer at DynaMed. Edited by Alan Ehrlich, MD, FAAFP, Executive Editor at DynaMed and Associate Professor in Family Medicine at the University of Massachusetts Medical School; Katharine DeGeorge, MD, MS, Senior Deputy Editor at DynaMed and Associate Professor of Family Medicine at the University of Virginia; Dan Randall, MD, MPH, FACP, Senior Deputy Editor at DynaMed; Vincent Lemaitre, PhD, Medical Editor at DynaMed; Rich Lamkin, MPH, MPAS, PA-C, Clinical Writer at DynaMed; Matthew Lavoie, BA, Senior Medical Copyeditor at DynaMed; Hannah Ekeh, MA, Senior Associate Editor II at DynaMed; and Jennifer Wallace, BA, Senior Associate Editor at DynaMed.