1
|
Mizubuti GB, Ho AMH, Silva LMD, Phelan R. Perioperative management of patients on glucagon-like peptide-1 receptor agonists. Curr Opin Anaesthesiol 2024; 37:323-333. [PMID: 38390914 DOI: 10.1097/aco.0000000000001348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW To summarize the mechanism of action, clinical outcomes, and perioperative implications of glucagon-like peptide-1 receptor agonists (GLP-1-RAs). Specifically, this review focuses on the available literature surrounding complications (primarily, bronchoaspiration) and current recommendations, as well as knowledge gaps and future research directions on the perioperative management of GLP-1-RAs. RECENT FINDINGS GLP-1-RAs are known to delay gastric emptying. Accordingly, recent case reports and retrospective observational studies, while anecdotal, suggest that the perioperative use of GLP-1-RAs may increase the risk of bronchoaspiration despite fasting intervals that comply with (and often exceed) current guidelines. As a result, guidelines and safety bulletins have been published by several Anesthesiology Societies. SUMMARY While rapidly emerging evidence suggests that perioperative GLP-1-RAs use is associated with delayed gastric emptying and increased risk of bronchoaspiration (particularly in patients undergoing general anesthesia and/or deep sedation), high-quality studies are needed to provide definitive answers with respect to the safety and duration of preoperative drug cessation, and optimal fasting intervals according to the specific GLP-1-RA agent, the dose/duration of administration, and patient-specific factors. Meanwhile, clinicians must be aware of the potential risks associated with the perioperative use of GLP-1-RAs and follow the recommendations put forth by their respective Anesthesiology Societies.
Collapse
Affiliation(s)
- Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Leopoldo Muniz da Silva
- Department of Anesthesiology, São Luiz Hospital - Rede D'Or - CMA, Rua Alceu de Campos Rodrigues, São Paulo, SP, Brazil
| | - Rachel Phelan
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| |
Collapse
|
2
|
Camilleri M, Lupianez-Merly C. Effects of GLP-1 and Other Gut Hormone Receptors on the Gastrointestinal Tract and Implications in Clinical Practice. Am J Gastroenterol 2024; 119:1028-1037. [PMID: 37753925 PMCID: PMC11026296 DOI: 10.14309/ajg.0000000000002519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/22/2023] [Indexed: 09/28/2023]
Abstract
Agonists targeting the receptors of incretin hormones, glucagon-like peptide-1 and glucose-dependent insulinotropic peptide, have been well established for the treatment of type 2 diabetes mellitus. There is increasing awareness that gastroenterologists and hepatologists should be treating obesity when patients present to their clinics. In addition, gastroenterologists and hepatologists should be aware of the effects of these classes of medications prescribed by other providers. Therefore, given the widespread use of incretin agonists for obesity treatment and weight loss, it is important to recognize their effects in the gastrointestinal tract, which could constitute significant benefits in weight loss and cardiometabolic benefits, but can be associated with adverse effects that constitute a potential barrier to their use, particularly at higher doses. Multiple studies reviewed in this article document the diverse effects of these drugs on the glucagon-like peptide-1 receptors that are widely expressed in the human body, including the nervous system modulating appetite, the gastrointestinal tract modifying gastric emptying, and lipid metabolism regulation leading to reduction in fat deposition. The objective of this review is to summarize the mechanism of action of incretin receptor agonists, their effects in the gastrointestinal tract, and implications in clinical practice, particularly in the practice of gastroenterology, endoscopy, and surgery.
Collapse
Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | |
Collapse
|
3
|
Xie C, Alkhouri N, Elfeki MA. Role of incretins and glucagon receptor agonists in metabolic dysfunction-associated steatotic liver disease: Opportunities and challenges. World J Hepatol 2024; 16:731-750. [PMID: 38818288 PMCID: PMC11135259 DOI: 10.4254/wjh.v16.i5.731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/18/2024] [Accepted: 04/03/2024] [Indexed: 05/22/2024] Open
Abstract
Metabolic dysfunction-associated steatotic liver disease (MASLD) has become the most common chronic liver disease worldwide, paralleling the rising pandemic of obesity and type 2 diabetes. Due to the growing global health burden and complex pathogenesis of MASLD, a multifaceted and innovative therapeutic approach is needed. Incretin receptor agonists, which were initially developed for diabetes management, have emerged as promising candidates for MASLD treatment. This review describes the pathophysiological mechanisms and action sites of three major classes of incretin/glucagon receptor agonists: glucagon-like peptide-1 receptor agonists, glucose-dependent insulinotropic polypeptide receptor agonists, and glucagon receptor agonists. Incretins and glucagon directly or indirectly impact various organs, including the liver, brain, pancreas, gastrointestinal tract, and adipose tissue. Thus, these agents significantly improve glycemic control and weight management and mitigate MASLD pathogenesis. Importantly, this study provides a summary of clinical trials analyzing the effectiveness and safety of incretin receptor agonists in MASLD management and provides an in-depth analysis highlighting their beneficial effects on improving liver function, hepatic steatosis, and intrahepatic inflammation. There are emerging challenges associated with the use of these medications in the real world, particularly adverse events, drug-drug interactions, and barriers to access, which are discussed in detail. Additionally, this review highlights the evolving role of incretin receptor agonists in MASLD management and suggests future research directions.
Collapse
Affiliation(s)
- Chencheng Xie
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD 57105, United States
- Department of Hepatology, Avera Mckennan University Hospital and Transplant Institute, Sioux Falls, SD 57105, United States
| | - Naim Alkhouri
- Department of Hepatology, Arizona Liver Health, Chandler, AZ 85712, United States
| | - Mohamed A Elfeki
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD 57105, United States
- Department of Hepatology, Avera McKennan University Hospital and Transplant Institute, Sioux Falls, SD 57105, United States.
| |
Collapse
|
4
|
Gariani K, Putzu A. Glucagon-like peptide-1 receptor agonists in the perioperative period: Implications for the anaesthesiologist. Eur J Anaesthesiol 2024; 41:245-246. [PMID: 38298102 PMCID: PMC10842663 DOI: 10.1097/eja.0000000000001914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Affiliation(s)
- Karim Gariani
- From the Division of Endocrinology, Diabetes, Nutrition and Therapeutic Patient Education, Department of Medical Specialties, Geneva University Hospitals, Geneva, Switzerland (KG), Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland (AP)
| | | |
Collapse
|
5
|
Villasenor M, Selzer AR. Preoperative Patient Evaluation: Newer Hypoglycemic Agents. Anesthesiol Clin 2024; 42:41-52. [PMID: 38278591 DOI: 10.1016/j.anclin.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
New medications in the treatment of diabetes are an active area of research and drug development. Although many hypoglycemic therapies have been in use for decades, new evidence continues to emerge highlighting benefits of these medications for other indications. In this article, the authors review the classes of newer hypoglycemic agents and summarize medications currently in phase 2 and 3 clinical trials. The literature to support specific recommendations for perioperative management is scant, however, where it exists, we have included it. In other instances, the authors have noted a reasonable approach based on pharmacokinetics and principles of perioperative medication management.
Collapse
Affiliation(s)
- Mario Villasenor
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Angela Roberts Selzer
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA.
| |
Collapse
|
6
|
Ushakumari DS, Sladen RN. ASA Consensus-based Guidance on Preoperative Management of Patients on Glucagon-like Peptide-1 Receptor Agonists. Anesthesiology 2024; 140:346-348. [PMID: 37982170 DOI: 10.1097/aln.0000000000004776] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Affiliation(s)
| | - Robert N Sladen
- Columbia University Irving Medical Center, New York, New York (R.N.S.).
| |
Collapse
|
7
|
Abstract
This review aims to provide a conceptual framework for preoperative evaluation and to highlight the clinical evidence available to support perioperative decision-making.
Collapse
Affiliation(s)
- Jeanna D Blitz
- Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
8
|
Modha K, Whinney C. Preoperative Evaluation for Noncardiac Surgery. Ann Intern Med 2022; 175:ITC161-ITC176. [PMID: 36343344 DOI: 10.7326/aitc202211150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The previous In the Clinic that addressed preoperative evaluation for noncardiac surgery was published in December 2016. This update reaffirms much of the information in the previous version and provides new information that has accumulated since then. The goal of preoperative assessment is to identify the risk for postoperative complications so health care teams can more fully understand how to implement strategies to mitigate risks before and after the operation.
Collapse
Affiliation(s)
- Kunjam Modha
- Cleveland Clinic Foundation, Cleveland, Ohio (K.M.)
| | | |
Collapse
|
9
|
Khambaty M, Silbert RE, Devalapalli AP, Kashiwagi DT, Regan DW, Sundsted KK, Mauck KF. Practice-Changing Updates in Perioperative Medicine Literature 2020-2021: A Systematic Review. Am J Med 2022; 135:1306-1314.e1. [PMID: 35820457 DOI: 10.1016/j.amjmed.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 06/20/2022] [Accepted: 06/20/2022] [Indexed: 11/17/2022]
Abstract
Recent literature published in a variety of multidisciplinary journals has significantly influenced perioperative patient care. Distilling and synthesizing the clinically important literature can be challenging. This review summarizes practice-changing articles in perioperative medicine from the years 2020 and 2021. Embase, Ovid, and EBM reviews databases were queried from January 2020 to December 2021. Inclusion criteria were original research, systematic review, meta-analysis, and important guidelines. Exclusion criteria were conference abstracts, case reports, letters, protocols, pediatric and obstetric articles, and cardiac surgery literature. Two authors reviewed each reference using the Distiller SR systematic review software (Evidence Partners Inc., Ottawa, Ont., Canada). A modified Delphi technique was used to identify 9 practice-changing articles. We identified another 13 articles for tabular summaries, as they were relevant to an internist's perioperative evaluation of a patient. Articles were selected to highlight the clinical implications of new evidence in each field. We have also pointed out limitations of each study and clinical populations where they are not applicable.
Collapse
Affiliation(s)
- Maleka Khambaty
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN.
| | - Richard E Silbert
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN
| | - Aditya P Devalapalli
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN
| | - Deanne T Kashiwagi
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN; Division of Internal Medicine, Sheikh Shakhbout Medical City in partnership with Mayo Clinic, Abu Dhabi, United Arab Emirates
| | - Dennis W Regan
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN
| | - Karna K Sundsted
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN
| | - Karen F Mauck
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN
| |
Collapse
|
10
|
Sahai SK, Balonov K, Bentov N, Bierle DMM, Browning LM, Cummings KC, Dougan BM, Maxwell M, Merli GJ, Oprea AD, Sweitzer B, Mauck KF, Urman RD. Preoperative Management of Cardiovascular Medications: A Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement. Mayo Clin Proc 2022; 97:1734-1751. [PMID: 36058586 DOI: 10.1016/j.mayocp.2022.03.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 01/19/2022] [Accepted: 03/21/2022] [Indexed: 10/14/2022]
Abstract
Cardiovascular conditions such as hypertension, arrhythmias, and heart failure are common in patients undergoing anesthesia for surgical or other procedures. Numerous guidelines from various specialty societies offer variable recommendations for the perioperative management of these medications. The Society for Perioperative Assessment and Quality Improvement identified a need to provide multidisciplinary evidence-based recommendations for preoperative medication management. The society convened a group of 13 members with expertise in perioperative medicine and training in anesthesiology or internal medicine. The aim of this consensus effort is to provide perioperative clinicians with guidance on the management of cardiovascular medications commonly encountered during the preoperative evaluation. We used a modified Delphi process to establish consensus. Twenty-one classes of medications were identified: α-adrenergic receptor antagonists, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, angiotensin receptor-neprilysin inhibitors, β-adrenoceptor blockers, calcium-channel blockers, centrally acting sympatholytic medications, direct-acting vasodilators, loop diuretics, thiazide diuretics, potassium-sparing diuretics, endothelin receptor antagonists, cardiac glycosides, nitrodilators, phosphodiesterase-5 inhibitors, class III antiarrhythmic agents, potassium-channel openers, renin inhibitors, class I antiarrhythmic agents, sodium-channel blockers, and sodium glucose cotransportor-2 inhibitors. We provide recommendations for the management of these medications preoperatively.
Collapse
Affiliation(s)
- Sunil K Sahai
- Department of Internal Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX.
| | - Konstantin Balonov
- Department of Anesthesiology and Perioperative Medicine, Tufts University School of Medicine, Boston, MA
| | - Nathalie Bentov
- Department of Family Medicine, University of Washington, Seattle, WA
| | | | | | | | - Brian M Dougan
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Megan Maxwell
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Geno J Merli
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Adriana D Oprea
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT
| | - BobbieJean Sweitzer
- University of Virginia School of Medicine, Charlottesville, VAkInova Health Systems, Falls Church, VA; Inova Health Systems, Falls Church, VA
| | - Karen F Mauck
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
11
|
|
12
|
Pfeifer KJ, Selzer A, Whinney CM, Rogers B, Naik AS, Regan D, Mendez CE, Urman RD, Mauck K. Preoperative Management of Gastrointestinal and Pulmonary Medications: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement. Mayo Clin Proc 2021; 96:3158-3177. [PMID: 34736777 DOI: 10.1016/j.mayocp.2021.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 07/17/2021] [Accepted: 08/20/2021] [Indexed: 01/20/2023]
Abstract
Perioperative medication management is integral to preoperative optimization but remains challenging because of a paucity of literature guidance. Published recommendations are based on the expert opinion of a small number of authors without collaboration from multiple specialties. The Society for Perioperative Assessment and Quality Improvement (SPAQI) recognized the need for consensus recommendations in this area as well as the unique opportunity for its multidisciplinary membership to fill this void. In a series of articles within this journal, SPAQI provides preoperative medication management guidance based on available literature and expert multidisciplinary consensus. The aim of this consensus statement is to provide practical guidance on the preoperative management of gastrointestinal and pulmonary medications. A panel of experts with anesthesiology, perioperative medicine, hospital medicine, general internal medicine, and medical specialty experience was drawn together and identified the common medications in each of these categories. The authors then used a modified Delphi approach to review the literature and to generate consensus recommendations.
Collapse
Affiliation(s)
- Kurt J Pfeifer
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI.
| | - Angela Selzer
- Department of Anesthesiology, University of Colorado, Boulder, CO
| | - Christopher M Whinney
- Department of Hospital Medicine, Cleveland Clinic Lerner College of Medicine, Cleveland, OH
| | - Barbara Rogers
- Department of Anesthesiology, The Ohio State Wexner Medical Center, Columbus, OH
| | - Amar S Naik
- Division of Gastroenterology, Loyola University Medical Center, Chicago, IL
| | - Dennis Regan
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Carlos E Mendez
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Karen Mauck
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
13
|
Soghomonyan S, Stoicea N, Bergese SD. Editorial: New Trends and Approaches in Perioperative Pharmacotherapy: An Update. Front Pharmacol 2021; 12:721075. [PMID: 34421616 PMCID: PMC8377719 DOI: 10.3389/fphar.2021.721075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 07/26/2021] [Indexed: 12/01/2022] Open
Affiliation(s)
- S Soghomonyan
- Department of Anesthesiology, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - N Stoicea
- Ohio State University College of Pharmacy, Columbus, Summa Health System, Akron, OH, United States
| | - S D Bergese
- Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States
| |
Collapse
|
14
|
Intra-dural intercommunications between dorsal roots of adjacent spinal nerves and their clinical significance. Surg Radiol Anat 2021; 43:1519-1526. [PMID: 33961081 DOI: 10.1007/s00276-021-02761-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The dorsal roots of adjacent spinal nerves are known to communicate with each other through rami communicantes. These intercommunications can cause deviations in the normal dermatomal organization which leads to errors during clinical decision-making. The objective of the study was to augment the existing knowledge of these communications which shall help minimize the diagnostic and therapeutic errors. METHODS The present study examined thirty cadaveric spinal cord specimens to document the data of intra-dural, intercommunications between dorsal roots of adjacent spinal nerves. RESULTS All the regions of the spinal cord exhibited the presence of intercommunications with variable frequency. The intercommunications were categorized into a total of nine groups based on their patterns. The levels of spinal cord exhibiting higher and lower frequencies of intercommunications were identified. CONCLUSION This information will be useful during the clinical evaluation of patients with spinal cord pathologies or radiculopathies. The outcomes of rhizotomy can also be improved with knowledge of intercommunications.
Collapse
|