Inform Your Anesthesiologist About GLP-1 Agonist Usage

Sep 12, 2023

Anesthesiologists are deeply divided on how to manage the increasing number of surgical patients taking GLP-1 receptor agonists. These medications elevate the risk of aspiration during surgery. While the prominent U.S. anesthesiology society recommends that patients stop using injectable forms of these drugs for seven days before surgery, some anesthesiologists are exploring alternative approaches, such as intubating all high-risk patients, even for minor procedures. Others are advocating for patients to discontinue these medications for weeks, not just days, or gradually reduce their doses.

This issue is currently a subject of intense debate within the anesthesia community, and opinions are sharply divided.

Last autumn, a patient on injectable semaglutide (known as Ozempic for type 2 diabetes and Wegovy for weight loss) who experienced regurgitation of stomach contents while sedated for a lumpectomy. Typically, medical professionals minimize aspiration risk by requiring patients to fast before scheduled surgery to ensure their stomachs remain empty.

In theory, their stomachs should be fairly empty, However, GLP-1 agonists, including the popular semaglutide, can significantly disrupt normal digestive processes. Users’ stomachs may not empty within the usual 90 minutes to 2 hours after a meal. This slower gastric emptying can cause patients to feel fuller, potentially leading to regurgitation of lingering food from days ago while they are under anesthesia and unable to cough to prevent airway blockage.

This situation increases the risk of food being inhaled into the lungs, a rare but severe event associated with a high likelihood of death or severe injury.

Anesthesiologists are deeply concerned to the point that “the anesthesia plan for any surgery involving a patient on these medications could be affected,” Some anesthesiologists are now considering intubation for patients on these drugs even for minor procedures and employing techniques usually reserved for high-risk aspiration cases.

Alarm has risen among anesthesiologists as the number of regurgitation cases has increased among surgery patients taking GLP-1 receptor agonists. In a distressing incident in October 2022, a 48-year-old woman undergoing a lumpectomy in Toronto began to regurgitate while under anesthesia, despite fasting from solid food for 20 hours and clear fluids for 8 hours.

Describing the incident, a case report published in the Canadian Journal of Anesthesia, stated, “It was very dramatic.” He and the medical team took immediate steps to ensure that stomach contents didn’t enter her airway, followed by intubation, and a bronchoscope inspection of her lungs. Fortunately, no stomach contents entered her airway.

While there haven’t been reported deaths resulting from aspiration during surgery after taking GLP-1 agonists, another case report in the same journal from Boston described a more troubling incident. An endoscopy patient on weekly semaglutide injections aspirated food from the stomach into the trachea and bronchi despite fasting for 18 hours. The food was removed via bronchoscope before intubation.

Several anesthesiologists have reported encountering numerous patients taking GLP-1 agonists, including those undergoing minor procedures that typically do not require intubation, such as colonoscopies, upper endoscopies, and breast biopsies.

These drugs have surged in popularity due to reports in medical literature and mainstream media about significant weight loss among users, including celebrities. For instance, a retrospective study in 2022 tracked 175 Mayo Clinic patients and found they lost an average of 5.9% of their weight at 3 months and 10.9% at 6 months while using injectable semaglutide.

In addition to injectable semaglutide (Ozempic and Wegovy), these medications include the oral version of semaglutide (Rybelsus), dulaglutide (Trulicity), exenatide (Byetta and Bydureon), and liraglutide (Saxenda and Victoza). Tirzepatide (Mounjaro), a GIP/GLP-1 agonist, shares similarities.

Despite reports of side effects like nausea, diarrhea, constipation, sulfurous burps, and even unusual dreams about famous people, their sales have surged. Wegovy, approved for weight loss, reportedly saw a 344% increase in U.S. sales during the first 6 months of the year.

Meanwhile, recent research has revealed how significantly these drugs slow down the digestive system. In one study, researchers in Slovenia administered injectable semaglutide or a placebo to 20 women with polycystic ovary syndrome and obesity for 12 weeks. At the study’s conclusion, 37% of meals remained in the stomachs of women taking the drug at 4 hours, compared to none in the placebo group.

Another study from Brazil found that upper endoscopy patients on semaglutide were significantly more likely than others to retain an abnormal amount of food in their stomachs despite fasting.

Strategies for managing this issue range from brief drug hiatuses to intubation. In a June 29 consensus statement, the American Society of Anesthesiologists (ASA) recommended that patients stop taking weekly doses of GLP-1 agonists for 7 days before procedures, with daily doses stopped for 1 day. For patients using GLP-1 agonists for diabetes management, consulting an endocrinologist for bridging antidiabetic therapy is advised if the drug needs to be held for a longer duration. The society maintains its existing fasting guidelines, as there is no evidence indicating the optimal fasting duration for patients on these drugs.

Dr. Daniel Cole, a UCLA anesthesiologist and former ASA president, supports these recommendations but notes their limited evidentiary basis. He emphasizes that the ASA is doing its best with the available data and that various approaches can be taken to protect patients.

At the McGovern Medical School at UTHealth Houston, Dr. Omonele Nwokolo and several colleagues are bypassing the ASA’s recommendations by intubating all patients using weight-loss drugs. The risk of dangerous or fatal pulmonary aspiration is substantial enough to warrant extra precautions, according to Nwokolo. Intubation is typically reserved for longer and more painful surgical procedures or emergencies where fasting history is unclear, and it must be assumed that patients’ stomachs are full. Nwokolo and colleagues employ rapid sequence induction, a technique used for specific situations such as emergent procedures and cases with fasting concerns.

However, Dr. Kathryn Cobb, a University of North Carolina anesthesiologist, cautions that intubation is not always a straightforward option, especially in procedural settings without anesthesia machines geared for intubation, where intubation is reserved for emergencies.

Dr. Cole adds that intubation carries risks like mouth and teeth damage, increased anesthetic doses impacting heart and vascular function, and delayed cognitive recovery.