Considerations of delayed gastric emptying with peri-operative use of glucagon-like peptide-1 receptor agonists

Management of pharmacotherapy in lung transplant candidates

PURPOSE OF REVIEW

Lung transplantation is a common treatment for end-stage lung disease (ESLD). Patients present to lung transplantation evaluation on various medications that could impact their candidacy and posttransplant course. In this review, we will discuss pretransplant optimization of pharmacotherapy to minimize complications while waiting for transplant and increase posttransplant success. We will also discuss important considerations for posttransplant immunosuppression, antimicrobial prophylaxis, and complex drug interactions.

RECENT FINDINGS

Prior to lung transplantation, several medications should be optimized to promote posttransplant success including minimization of corticosteroids, opioids, and benzodiazepines. Lung transplantation candidates should be up to date on vaccinations. Most medications for ESLD are well tolerated to continue up until the point of transplant including antifibrotics, CFTR modulators, and pulmonary vasodilators. Mammalian target of rapamycin inhibitors and other immunosuppressants may need to be stopped or minimized before lung transplantation to minimize posttransplant infection and would healing complications. Medications that increase risk of posttransplant bleeding, thrombosis, or aspiration should be stopped prior to listing.

SUMMARY

In this article, we discuss management of pharmacotherapy for lung transplantation candidates to minimize posttransplant complications. Changes in medications for ESLD should be done cautiously to prevent worsening of native disease while waiting for lung transplantation.

Perioperative management of patients taking glucagon-like peptide 1 receptor agonists: Society for Perioperative Assessment and Quality Improvement (SPAQI) multidisciplinary consensus statement

The perioperative management of patients using glucagon-like peptide 1 receptor agonists remains a topic of debate. While several multisociety statements have been published recently, the recommendations vary significantly in terms of medication management and preoperative fasting protocols for these patients. This document represents a multidisciplinary consensus statement led by the Society for Perioperative Assessment and Quality Improvement (SPAQI). It provides updated recommendations based on a modified Delphi process and supported by a systematic review of the current literature. The recommendations address management of the glucagon-like peptide 1 receptor agonists perioperatively, and preoperative fasting times for both solids and liquids. SYSTEMATIC REVIEW PROTOCOL: PROSPERO (CRD42023438624).

A case series of incidents reported to webAIRS relating to glucagon-like peptide 1 agonist use

The increasing prescription of glucagon-like peptide 1 (GLP-1) agonists presents a peri-operative challenge for anaesthetists. These drugs delay gastric emptying, potentially increasing pulmonary aspiration risk. Despite recent recommendations from the Australian and New Zealand College of Anaesthetists, Australian Society of Anaesthetists, and American Society of Anesthesiologists, there remain no formalised guidelines regarding preoperative optimisation for patients taking GLP-1 agonists. Given the current lack of evidence, we present a case series of incidents involving patients treated with GLP-1 agonists reported to webAIRS, a web-based anaesthetic incident reporting system in Australia and New Zealand. Among 11,700 reports from July 2009 to April 2024, 13 incidents related to GLP-1 agonist use were identified, including seven cases concerning aspiration. Patient factors potentially contributing to increased aspiration risks in these incidents included a higher body mass index, type 2 diabetes mellitus, gastro-oesophageal reflux disease, emergency case, and time from GLP-1 agonist cessation. Most incidents involved a rapid sequence induction for general anaesthesia with no cases utilising gastric ultrasound, preoperative nasogastric tube insertion, or intravenous erythromycin use. This case series highlights the potential concerns relating to GLP-1 treatment in the perioperative setting. Interdisciplinary collaboration and communication between anaesthetists, surgeons, general practitioners and endocrinologists are required to further investigate and establish preoperative guidelines for safe GLP-1 agonist use. Specifically, consideration in determining actual gastric contents of each patient despite generic fasting guidelines is needed. Early preoperative risk stratification should also improve patient safety and outcomes.

Perioperative and periprocedural management of GLP-1 receptor-based agonists and SGLT2 inhibitors: narrative review and the STOP-GAP and STOP DKA-2 algorithms

The GLP-1 receptor-based agonists (GLP-1RAs) and SGLT2 inhibitors (SGLT2i) are major twenty first century breakthroughs in diabetes and obesity medicine but there are important safety considerations regarding the perioperative and periprocedural management of individuals who are treated with these agents. GLP-1RAs have been linked to an increased risk of retained gastric contents and pulmonary aspiration while SGLT2i can be associated with diabetic ketoacidosis. This manuscript provides a narrative review of the available evidence for perioperative and periprocedural risks in people prescribed GLP-1RAs and SGLT2i. The authors provide expert opinion-driven recommendations and algorithms on how to safely manage GLP-1RAs and SGLT2i under perioperative/periprocedural settings.

Role of Point-of-Care Gastric Ultrasound in Advancing Perioperative Fasting Guidelines

Pulmonary aspiration in the perioperative period carries the risk of significant morbidity and mortality. As such, guidelines have been developed with the hopes of minimizing this risk by recommending fasting from solids and liquids over a specified amount of time. Point-of-care ultrasound has altered the landscape of perioperative medicine; specifically, gastric ultrasound plays a pivotal role in perioperative assessment. Further, the advent of glucagon-like-peptide-1 receptor agonists, the widespread use of cannabis, and Enhanced Recovery program carbohydrate beverage presents new challenges when attempting to standardize fasting guidelines. This review synthesizes the literature surrounding perioperative fasting guidelines specifically with regard to the use of point-of-care ultrasound in assessing for gastric contents and minimizing the risk of aspiration.

Impact of GLP-1 Receptor Agonists in Gastrointestinal Endoscopy: An Updated Review

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have become one of the most popular medications for patients with diabetes and obesity. Due to their effects on gut motility via central or parasympathetic pathways, there have been concerns about an increased incidence of retained gastric contents and risk of aspiration in the perioperative period. Hence, the American Society of Anesthesiologists (ASA) recommends holding GLP-1 RAs on the procedure day or a week before the elective procedure based on the respective daily or weekly formulations, regardless of the dose, indication (obesity or diabetes), or procedure type. On the contrary, the American Gastroenterological Association (AGA) advises an individualized approach, stating that more data are needed to decide if and when the GLP-1 RAs should be held prior to elective endoscopy. Several retrospective and prospective studies, along with meta-analyses, have been published since then evaluating the role of GLP-1 RAs in patients scheduled for endoscopic procedures. In this review, we discuss the current clinical guidelines and available studies regarding the effect of GLP-1 RAs on GI endoscopies.

Glucagon-like peptide-1 receptor agonists: a narrative review of clinical pharmacology and implications for peri-operative practice

BACKGROUND

Glucagon-like peptide-1 receptor agonists are used increasingly in the management of patients living with type 2 diabetes mellitus and obesity. In patients using glucagon-like peptide-1 receptor agonists, a key concern in the peri-operative period is the increased risk of pulmonary aspiration due to delayed gastric emptying. This review provides an overview of the pharmacodynamic and pharmacokinetic properties of glucagon-like peptide-1 receptor agonists and the risk of delayed gastric emptying and aspiration.

METHODS

We conducted searches of MEDLINE and EMBASE databases of articles published before January 2024 using the keywords and medical subject headings: incretins; glucagon-like peptide-1; GLP-1; glucagon-like peptide-1 receptor agonists; GLP-1 RA; peri-operative period; perioperative; peri-operative; stomach emptying; gastric emptying; pulmonary aspiration; aspiration; food regurgitation; and regurgitation. The evidence was analysed, synthesised and reported narratively.

RESULTS

A total of 1213 articles were located after duplicates were removed. Two authors screened the titles and abstracts to identify those studies which assessed specifically the risk of delayed gastric emptying and pulmonary aspiration or regurgitation in the peri-operative period. We searched manually the reference lists of relevant studies to identify any additional case reports. Ten studies were identified. Available evidence was limited to case reports, case series and observational work.

CONCLUSIONS

There is insufficient evidence to put forward definitive guidance regarding the ideal cessation period for glucagon-like peptide-1 receptor agonists before elective surgery. Precautionary practice is required until more evidence becomes available. We suggest an individualised, evidence-based approach. In patients living with type 2 diabetes mellitus, there is concern that prolonged cessation before surgery will have a detrimental effect on peri-operative glycaemic control and discussion with an endocrinologist is advised. For patients taking glucagon-like peptide-1 receptor agonists for weight management, these drugs should be withheld for at least three half-lives before an elective surgical procedure.

Impact of glucagon-like peptide receptor agonists on endoscopy and its preoperative management: Guidelines, challenges, and future directions

Glucagon-like peptide receptor agonists (GLP-1RA) are used to treat type 2 diabetes mellitus and, more recently, have garnered attention for their effectiveness in promoting weight loss. They have been associated with several gastrointestinal adverse effects, including nausea and vomiting. These side effects are presumed to be due to increased residual gastric contents. Given the potential risk of aspiration and based on limited data, the American Society of Anesthesiologists updated the guidelines concerning the preoperative management of patients on GLP-1RA in 2023. They included the duration of mandated cessation of GLP-1RA before sedation and usage of "full stomach" precautions if these medications were not appropriately held before the procedure. This has led to additional challenges, such as extended waiting time, higher costs, and increased risk for patients. In this editorial, we review the current societal guidelines, clinical practice, and future directions regarding the usage of GLP-1RA in patients undergoing an endoscopic procedure.