This transcript has been edited for clarity.
Akshay B. Jain, MD: Welcome back to ADA 2024 updates. I'm endocrinologist Dr Akshay Jain from Vancouver in Canada, and today we've got a very special guest. We've got Professor Dr Girish Joshi. Dr Joshi is a professor of anesthesiology and pain medicine at UT Southwestern in Dallas, Texas.
He was one of the speakers at a very impactful session that was talking about the postoperative and intraoperative considerations for people who are on GLP-1 therapy. He's here to talk with us about clinical considerations that one needs to keep in mind when someone on glucagon-like peptide 1 (GLP-1) receptor agonist therapy is undergoing elective procedures. Welcome, Dr Joshi.
Girish P. Joshi, MD: Thank you, Akshay. It's an honor.
Jain: I was attending your session, and I found it very clinically impactful. This is something that we are seeing more and more in clinical practice. For our viewers today, can you share with us, as an anesthesiologist, the potential risks for aspiration and the rates of aspiration that you're seeing in people who are on GLP-1 therapy?
Joshi: We don't know the exact rate of aspiration with GLP-1 therapy because there are no good studies, but there are several anecdotal reports, including several personal communications where people have contacted me and the American Society of Anesthesiologists (ASA). I'm the chair of the task force for these GLP-1 recommendations developed by the ASA.
To give an example, one of the cases reported to me was from a colleague in Dallas where a patient, otherwise completely healthy, came in for a shoulder arthroscopy — a simple outpatient procedure in a freestanding ambulatory surgery center.
Surgery went fine. At the end of the procedure, she regurgitated gastric content and aspirated, and then had to be taken to the intensive care unit (ICU) and she spent 7 days in the ICU. Retrospectively, it was recognized that she was on GLP-1 therapy for weight loss, which was not disclosed. This was just before the ASA came up with the guidance, basically, so people didn't know that GLP-1 receptor agonists do increase the risk for aspiration.
Jain: That's a really good point straight from your clinical practice. For our viewers who may not be familiar with the guidelines, could you tell us, in a nutshell, for people on GLP-1 therapy who are going in for an elective procedure that requires general anesthesia, what would be the recommendations for holding GLP-1s?
Joshi: I have to first emphasize that currently, the evidence to provide any guidance is sparse, and whatever studies are available are basically questionable or of poor quality. With that said, the reason why the ASA came up with the guidance was to inform our colleagues, anesthesiologists, as well as our colleagues from surgery and other proceduralists of this concern about increased regurgitation and aspiration in patients on GLP-1 receptor agonists. That was the primary aim.
Because the evidence is sparse, we basically came up with different approaches to decrease or mitigate the risk for regurgitation and aspiration. It starts with having a collaborative discussion, including the patients, or shared decision-making with the physicians and the patient regarding the potential risks, so mention to the patient that there is a potential risk.
Then, avoid the elective procedures in patients at high risk. Examples of patients at high risk would be those who are basically in the escalation phase of the GLP-1 therapy, patients with prior history of gastroparesis, or patients on drugs that can cause gastroparesis.
I don't know whether you remember I had an algorithm I developed and presented at the American Diabetes Association (ADA) meeting, where I presented the potential risk factors. If the patients are at risk for regurgitation and aspiration, that's the patient population we've got to be extra careful with. Maybe start off withholding the drug if the patients are on, say, a weekly therapy, then 1 week before, though the evidence is minimal. Nevertheless, more importantly, avoid elective procedures during that escalation phase in this patient population.
When the patient comes for the procedure, on the day of procedure, if they have significant gastrointestinal (GI) symptoms, then avoid elective procedures. Alternatively, you can do what we call a gastric ultrasound to look at the stomach content. If the patient has stomach content, then maybe either delay surgery or use what we call rapid sequence induction of anesthesia, which will mitigate the risk for regurgitation and aspiration.
Jain: These are very important points. Thanks, Dr Joshi. I think the key concept here is communication with all stakeholders. What I generally do in my clinical practice as well is, of course, avoiding escalation of GLP-1 therapy, especially with surgery around the corner. At the same time, if patients are still having active symptoms of nausea or symptoms that suggest that they could be having other gastrointestinal discomfort, I would even de-escalate or decrease the dose of the GLP-1 as well, because we know the GI side effects are quite dose dependent.
In preparation for elective surgery, it's a good idea to start well ahead of time. Obviously, if we are not able to increase GLP-1 therapy or if you have to de-escalate GLP-1 therapy, it would also be very important to focus on glycemic control because we know that if sugars get out of hand, that's a different story for perioperative complications as well. You put forward a very good point. The key is communication between all stakeholders, keeping the patient in the center.
We live in a day and age where, of course, one drug can have many indications. Same goes for GLP-1 therapy or GLP-1/ glucose-dependent insulinotropic polypeptide (GIP) therapy, a very similar class. We know these agents are being used for both the management of type 2 diabetes and management of obesity or overweight. Would the recommendations be any different for someone who's taking these medications for obesity and not for diabetes?
Joshi: No. In fact, it doesn't really matter what the indication for the drug is. It's the drug that causes the problem. Our approach to managing the patients, whether they are on these drugs for weight loss or for diabetes, would not change.
Jain: I know the evidence is quite sparse, but it looks like the need of the hour is to look at more prospective trials that give us a better idea.
One final question for you: When would it be safe for patients to resume their GLP-1 therapy? Keeping in mind that there's individual variations, from a postoperative point of view, if it's being held, when would be a safe time for us to restart it?
Joshi: I do want to emphasize that we prefer not to hold the drugs if possible. If patients are not in that high-risk category, preferably, we would not want to hold these drugs because they do maintain the perioperative or periprocedural blood sugar control. Preferably, we do not stop these drugs unless they are in that high-risk population. If the drugs have been stopped, then they need to be resumed as early as possible.
Typically, with the current approach to perioperative care, I don't know whether you've heard about this concept of enhanced recovery after surgery. It has revolutionized the approach to perioperative care, where we basically, even after abdominal surgical procedures, have the patient consume oral intake literally within hours after surgery. That's why we need to start these drugs as soon as possible, assuming they don't have any GI issues.
Jain: These are such excellent clinical pearls, Dr Joshi. It's not often we get to have a face-to-face interaction with anesthesiology and endocrinology for management of GLP-1 in patients who are undergoing surgery. We really appreciate this opportunity, and thanks for sharing your time with us.
Joshi: Thank you, Akshay.
COMMENTARY
GLP-1 Guidance to Reduce Regurgitation and Aspiration Risk
Akshay B. Jain, MD, FRCPC, FACE, CCD, ECNU, DABOM; Girish P. Joshi, MBBS, MD, FFARCSI
DISCLOSURES
| July 18, 2024This transcript has been edited for clarity.
Akshay B. Jain, MD: Welcome back to ADA 2024 updates. I'm endocrinologist Dr Akshay Jain from Vancouver in Canada, and today we've got a very special guest. We've got Professor Dr Girish Joshi. Dr Joshi is a professor of anesthesiology and pain medicine at UT Southwestern in Dallas, Texas.
He was one of the speakers at a very impactful session that was talking about the postoperative and intraoperative considerations for people who are on GLP-1 therapy. He's here to talk with us about clinical considerations that one needs to keep in mind when someone on glucagon-like peptide 1 (GLP-1) receptor agonist therapy is undergoing elective procedures. Welcome, Dr Joshi.
Girish P. Joshi, MD: Thank you, Akshay. It's an honor.
Jain: I was attending your session, and I found it very clinically impactful. This is something that we are seeing more and more in clinical practice. For our viewers today, can you share with us, as an anesthesiologist, the potential risks for aspiration and the rates of aspiration that you're seeing in people who are on GLP-1 therapy?
Joshi: We don't know the exact rate of aspiration with GLP-1 therapy because there are no good studies, but there are several anecdotal reports, including several personal communications where people have contacted me and the American Society of Anesthesiologists (ASA). I'm the chair of the task force for these GLP-1 recommendations developed by the ASA.
To give an example, one of the cases reported to me was from a colleague in Dallas where a patient, otherwise completely healthy, came in for a shoulder arthroscopy — a simple outpatient procedure in a freestanding ambulatory surgery center.
Surgery went fine. At the end of the procedure, she regurgitated gastric content and aspirated, and then had to be taken to the intensive care unit (ICU) and she spent 7 days in the ICU. Retrospectively, it was recognized that she was on GLP-1 therapy for weight loss, which was not disclosed. This was just before the ASA came up with the guidance, basically, so people didn't know that GLP-1 receptor agonists do increase the risk for aspiration.
Jain: That's a really good point straight from your clinical practice. For our viewers who may not be familiar with the guidelines, could you tell us, in a nutshell, for people on GLP-1 therapy who are going in for an elective procedure that requires general anesthesia, what would be the recommendations for holding GLP-1s?
Joshi: I have to first emphasize that currently, the evidence to provide any guidance is sparse, and whatever studies are available are basically questionable or of poor quality. With that said, the reason why the ASA came up with the guidance was to inform our colleagues, anesthesiologists, as well as our colleagues from surgery and other proceduralists of this concern about increased regurgitation and aspiration in patients on GLP-1 receptor agonists. That was the primary aim.
Because the evidence is sparse, we basically came up with different approaches to decrease or mitigate the risk for regurgitation and aspiration. It starts with having a collaborative discussion, including the patients, or shared decision-making with the physicians and the patient regarding the potential risks, so mention to the patient that there is a potential risk.
Then, avoid the elective procedures in patients at high risk. Examples of patients at high risk would be those who are basically in the escalation phase of the GLP-1 therapy, patients with prior history of gastroparesis, or patients on drugs that can cause gastroparesis.
I don't know whether you remember I had an algorithm I developed and presented at the American Diabetes Association (ADA) meeting, where I presented the potential risk factors. If the patients are at risk for regurgitation and aspiration, that's the patient population we've got to be extra careful with. Maybe start off withholding the drug if the patients are on, say, a weekly therapy, then 1 week before, though the evidence is minimal. Nevertheless, more importantly, avoid elective procedures during that escalation phase in this patient population.
When the patient comes for the procedure, on the day of procedure, if they have significant gastrointestinal (GI) symptoms, then avoid elective procedures. Alternatively, you can do what we call a gastric ultrasound to look at the stomach content. If the patient has stomach content, then maybe either delay surgery or use what we call rapid sequence induction of anesthesia, which will mitigate the risk for regurgitation and aspiration.
Jain: These are very important points. Thanks, Dr Joshi. I think the key concept here is communication with all stakeholders. What I generally do in my clinical practice as well is, of course, avoiding escalation of GLP-1 therapy, especially with surgery around the corner. At the same time, if patients are still having active symptoms of nausea or symptoms that suggest that they could be having other gastrointestinal discomfort, I would even de-escalate or decrease the dose of the GLP-1 as well, because we know the GI side effects are quite dose dependent.
In preparation for elective surgery, it's a good idea to start well ahead of time. Obviously, if we are not able to increase GLP-1 therapy or if you have to de-escalate GLP-1 therapy, it would also be very important to focus on glycemic control because we know that if sugars get out of hand, that's a different story for perioperative complications as well. You put forward a very good point. The key is communication between all stakeholders, keeping the patient in the center.
We live in a day and age where, of course, one drug can have many indications. Same goes for GLP-1 therapy or GLP-1/ glucose-dependent insulinotropic polypeptide (GIP) therapy, a very similar class. We know these agents are being used for both the management of type 2 diabetes and management of obesity or overweight. Would the recommendations be any different for someone who's taking these medications for obesity and not for diabetes?
Joshi: No. In fact, it doesn't really matter what the indication for the drug is. It's the drug that causes the problem. Our approach to managing the patients, whether they are on these drugs for weight loss or for diabetes, would not change.
Jain: I know the evidence is quite sparse, but it looks like the need of the hour is to look at more prospective trials that give us a better idea.
One final question for you: When would it be safe for patients to resume their GLP-1 therapy? Keeping in mind that there's individual variations, from a postoperative point of view, if it's being held, when would be a safe time for us to restart it?
Joshi: I do want to emphasize that we prefer not to hold the drugs if possible. If patients are not in that high-risk category, preferably, we would not want to hold these drugs because they do maintain the perioperative or periprocedural blood sugar control. Preferably, we do not stop these drugs unless they are in that high-risk population. If the drugs have been stopped, then they need to be resumed as early as possible.
Typically, with the current approach to perioperative care, I don't know whether you've heard about this concept of enhanced recovery after surgery. It has revolutionized the approach to perioperative care, where we basically, even after abdominal surgical procedures, have the patient consume oral intake literally within hours after surgery. That's why we need to start these drugs as soon as possible, assuming they don't have any GI issues.
Jain: These are such excellent clinical pearls, Dr Joshi. It's not often we get to have a face-to-face interaction with anesthesiology and endocrinology for management of GLP-1 in patients who are undergoing surgery. We really appreciate this opportunity, and thanks for sharing your time with us.
Joshi: Thank you, Akshay.
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
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