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GLP-1 medications safe to continue before surgery in patients with diabetes and obesity

There are only mild differences in gastric emptying among patients taking glucagon-like peptide-1 (GLP-1) receptor agonist medications for type 2 diabetes and weight loss, according to a meta-analysis and review of 15 randomised studies by researchers from Brigham and Women’s Hospital. Their findings suggest that patients may be able to continue taking the medications prior to their surgeries without a high risk of aspiration.

As more patients begin taking medications to help manage blood sugar levels and weight loss, concerns about whether these medications are safe to take prior to anaesthesia or sedation have emerged. Investigators from Brigham looked at the results from RCTs of patients taking GLP-1s receptor agonist medications and found that the medications had a gastric emptying delay of only about 36 minutes for solid foods.


"While GLP-1 medications affect gastrointestinal tract motility, their quantified impact may not be as significant as previously assumed,” said corresponding author, Dr Walter Chan, director of the Center of Gastrointestinal Motility and a physician in the Brigham's Division of Gastroenterology, Hepatology and Endoscopy. “It appears safe to continue these medications before a procedure requiring anaesthesia or sedation, with minor precautions like abstaining from solid food for a day to minimize any potential risk of aspiration.”


Recent reports and studies suggest that taking GLP-1 medications is associated with slower digestion with a larger amount of food remaining in the stomach. This raises concerns about the risk of patients taking GLP-1 medications choking while under anaesthesia during surgery.


The American Society of Anesthesiologists (ASA) recommends that patients refrain from taking GLP-1 medications for up to a week before elective surgeries and procedures. They also advise considering procedure delay if gastrointestinal symptoms persist or medication use is ongoing.


Conversely, the American Gastroenterological Association (AGA) suggests proceeding with planned procedures for patients adhering to standard pre-procedure precautions. Given the conflicting guidelines and lack of conclusive data surrounding perioperative care for patients using GLP-1 medications, the research team conducted a systematic review and meta-analysis of placebo-controlled studies, quantitatively assessing gastric emptying in adults treated for diabetes or excess body weight with GLP-1 medications, with the objective of providing insights relevant for guiding periprocedural management decisions.


Their analysis encompassed 15 unique RCTs, involving a total of 652 patients. Various methods were employed to measure gastric emptying in studies that included patients taking different GLP-1 medications, including both long-acting and short-acting formulations.


Five studies (n=247) utilised gastric emptying scintigraphy. Mean T1/2 was 138.4 minutes for GLP-1 RA vs 95.0 minutes for placebo, with a pooled mean difference of 36.0 minutes (p<0.01). Ten studies (n=411) utilised the acetaminophen absorption test, with no significant delay in gastric emptying measured by Tmax, area under the curve (AUC)4hr, and AUC5hr with GLP-1 RA (p>0.05). On meta-regression, the type of GLP-1 RA, mechanism of action, and treatment duration did not impact gastric emptying (p>0.05).


Researchers found that the difference in the time it took for half of ingested food to move from the stomach to the small intestine was just 36 minutes longer for patients taking GLP-1 medications, a relatively small amount of time compared to the standard periprocedural fasting period of eight hours.


Additionally, there were no substantial differences observed in the gastric emptying time of liquids, and no significant variation between the gastric emptying times associated with long-acting and short-acting GLP-1 medications. Notably, none of the participants in any of the studies analyzed by the team experienced pulmonary aspiration attributable to emptying delay during their procedures.


Due to the limited number of eligible studies, researchers were unable to stratify their analysis by indication of GLP-1 medications or to conduct further examination of studies utilising certain diagnostic modalities such as breath testing. However, the results hold promise for informing future research and guidelines concerning perioperative care for patients using GLP-1 medication.


"Based on our study, we recommend that guidelines be updated with the following precautions for GLP-1 RA users undergoing endoscopic procedures: continue therapy, follow a liquid-only diet the day prior, and adhere to standard pre-anaesthesia fasting," said lead author, Dr Brent Hiramoto, senior gastroenterology Fellow at Brigham and Women's Hospital. "Until more data on solid diets is available, a conservative approach with a liquid diet while continuing therapy is advisable."


The findings were reported in the paper, ‘Quantified Metrics of Gastric Emptying Delay by Glucagon-Like Peptide-1 Agonists: A Systematic Review and Meta-Analysis With Insights for Periprocedural Management’, published in The American Journal of Gastroenterology. To access this paper, please click here

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