With the inflation of prescriptions for glucagon-like peptide-1 receptor agonists like Ozempic, Mounjaro and Wegovy, physicians began seeing a startling amount of regurgitation and aspiration in surgeries.
GLP-1s delay gastric emptying, meaning normal fasting rules weren't cutting it.
In response to anecdotal reports and case studies, the American Society of Anesthesiologists published a guideline in June recommending patients stop taking GLP-1s within the half life period — such as skipping one week's semaglutide injection — before undergoing anesthesia.
The ASA and the American Gastroenterological Association have slightly different recommendations when it comes to GLP-1s and whether to delay surgeries, though.
On many points, the ASA and the AGA agree: There isn't much data to support stopping GLP-1 use before elective surgeries, and not performing an endoscopy can result in a missed cancer diagnosis. Also, both organizations recommend rapid-sequence induction for patients who took their GLP-1 dose and are experiencing gastrointestinal adverse events, such as severe nausea, vomiting or abdominal pain.
There's one area resulting in a "clinical dilemma," according to the AGA. Christopher C. Thompson, MD, who helped draft the gastroenterological group's Nov. 7 statement, said after the ASA's June guidance, "many of our cases were being canceled, and this was problematic for patients."
Dr. Thompson is the director of endoscopy at Boston-based Brigham and Women's Hospital and co-director of its Center for Weight Management and Wellness. He said delaying surgeries should be the last option available because the disruption not only upsets patients who undergo bowel prep but can also result in a longer delay depending on whether they can take off work again soon.
In August, the AGA; American Association for the Study of Liver Diseases; American College of Gastroenterology; American Society for Gastrointestinal Endoscopy; and North American Society for Pediatric Gastroenterology, Hepatology & Nutrition wrote a multi-society statement emphasizing the lack of evidence in the decision to halt GLP-1 regimens before surgeries.
Dexter Turnquest, MD, a bariatric surgeon at Houston Methodist Willowbrook Hospital, told Becker's that, between the ASA and AGA, "I think there is room for both opinions." If the surgery is elective, consider delaying if the patient takes their GLP-1 dose and has GI issues, but if it's an urgent procedure or a suspicion of cancer, proceed with "full stomach" precautions.
"If [halting a surgery] is not possible, that's OK," Girish Joshi, MD, vice chair of the ASA's Committee on Practice Parameters, said. "We are not saying cancel every case where the patient has not stopped the drug."
Dr. Thompson countered the ASA's stance, adding that opiates delay gastric emptying but patients taking opioids are not told to skip a dose.
Both organizations cited the same evidence and are concerned about patient safety, according to Dr. Joshi and Joshua Knight, MD, an anesthesiologist and UPMC's medical director of quality.
"In general, gastroenterologists are supporting the ASA recommendations and collaborating at endoscopy centers [and] hospitals to maintain a uniform safety approach," Benjamin Levy, MD, a gastroenterologist at UChicago Medicine, said. He added that the head of patient beds could be fixed at a 45-degree angle to minimize the aspiration risk.
Alfred Trang, MD, medical director of general surgery for Livonia, Mich.-based Trinity Health Mid-Atlantic, said he's leaning toward caution and following the ASA's guidance. Dr. Knight, an anesthesiologist, said the same.
"They're the ones who have to deal with the consequences of a patient who aspirates with induction of anesthesia," Dr. Trang, a bariatric surgeon, said. "So whatever they feel comfortable with I feel is reasonable because at the end of the day, I feel the person who makes the recommendations should be the ones who also deal with the consequences."
Amid the minimal data, there's a lot of room for leeway and clinical judgment, Dr. Turnquest, Dr. Trang and Dr. Knight said.
There are multiple scenarios that require considerations, such as whether the patient is taking a GLP-1 for weight loss or diabetes — if the latter, Dr. Joshi recommends consulting with an endocrinologist to bridge the antidiabetic therapy with supplemental insulin, which can increase the likelihood of hypoglycemia.
Dr. Trang raised concerns about whether conducting ultrasounds to find matter in the stomach is practical in OR workflows and perioperative settings, and Dr. Thompson said many ASCs aren't readily equipped for rapid-sequence inductions.
Another unknown is when patients should restart taking the GLP-1, according to Tim Schaffner, MD, a bariatric surgeon at Bon Secours in Hampton Roads, Va. He typically removes them temporarily from patients' regimens after surgeries because of the risk of nausea, vomiting and gallstones.
Dr. Thompson and Dr. Trang all raised concerns about the long-term effects of GLP-1s because of the surge of off-label prescriptions for weight loss. (Many GLP-1s are approved for diabetes; only three are indicated for chronic weight management.)
At Dr. Schaffner's practice, there's a 15% reduction in operations because of the popularity of GLP-1s — and this fits a national trend, he said. The "ultimate question," he said, is whether patients tolerate the drugs long term and can keep the weight off in a cost-effective balance compared to the upfront price of surgery.
"What [does] the patient who's been on Wegovy for three years look like compared to a patient who had surgery three years out?" Dr. Schaffner said. "I think the pendulum is gonna swing back."
If the pendulum swings back, physicians are waiting to have more data before enforcing a stronger clinical stance.
"[The ASA's guideline] was built with the appropriate level of evidence that is available at this time, and although we are happy to see this document now, we are also eager to see further evidence that may change this in the future," Dr. Knight said.