The American Society of Anesthesiologists (ASA) has created consensus-based recommendations for the preoperative care of patients on GLP-1 receptor agonists to manage the hazards associated with these medications. These recommendations offer a framework for reducing the possibility of aspiration and regurgitation while maintaining the therapeutic advantages of GLP-1 receptor agonists.
Preoperative Evaluation and Glycemic Control
Prior to surgery, it's important to conduct a thorough assessment, which should cover the patient's complete medication history and the timing of their last dosage of GLP-1 receptor agonist. As many patients rely on GLP-1 receptor agonists for managing their blood sugar levels, healthcare professionals should have a plan to manage blood glucose levels if the patient is unable to take the medication. Depending on the patient's specific needs and the expected duration of fasting, it may be necessary to use short-acting insulin or other medications to lower blood glucose levels.
Postponing GLP-1 Receptor Agonists Use Before Surgery
Routine discontinuation of GLP-1 receptor agonists before elective surgery is no longer recommended for most patients. Current multi-society guidance suggests that most patients may continue their GLP-1 receptor agonist therapy prior to elective procedures.
Instead of routinely withholding these medications, clinicians should evaluate individual patient risk factors for delayed gastric emptying and aspiration. Temporary withholding of GLP-1 receptor agonists may be considered in higher-risk situations, including:
- Patients in the early dose-escalation phase of therapy
- Patients experiencing significant gastrointestinal symptoms such as nausea, vomiting, or abdominal bloating
- Patients with known gastroparesis or other causes of delayed gastric emptying
- Patients receiving higher doses for weight management
In patients without these risk factors, continuation of GLP-1 receptor agonists along with standard fasting guidelines is generally appropriate.
However, when determining whether to stop administering GLP-1 receptor agonists, it is important to consider the patient's overall health, including the potential for hyperglycemia and associated risks. In individuals with inadequately managed diabetes, seeking advice from an endocrinologist can be essential to develop a transition plan utilizing another substitute anti-diabetic drug.
Preoperative Diet Recommendation
For patients considered to have an increased risk of delayed gastric emptying, clinicians may consider additional strategies to reduce residual gastric volume prior to anesthesia. One option is the use of a 24-hour clear liquid diet before surgery, which may help minimize gastric contents while allowing continuation of GLP-1 receptor agonist therapy.
This strategy may be particularly useful for patients in the early stages of GLP-1 therapy or those reporting mild gastrointestinal symptoms.
Risk Stratification for Patients Using GLP-1 Receptor Agonists
Low Risk
- Long-term stable GLP-1 therapy
- No gastrointestinal symptoms
Intermediate Risk
- Recent dose escalation
- Mild gastrointestinal symptoms
High Risk
- Severe nausea or vomiting
- Known gastroparesis
- Significant abdominal distention
| Scenario | Features | Management |
|---|---|---|
| Low | Long-term stable GLP-1 therapy; no gastrointestinal symptoms | Continue the medication and follow standard fasting guidelines |
| Intermediate | Recent dose escalation; mild gastrointestinal symptoms | Consider a 24-hour clear liquid diet or gastric ultrasound |
| High | Severe nausea or vomiting; known gastroparesis; significant abdominal distention | Consider delaying elective surgery, or treat the patient as having a full stomach |
| Emergency or urgent (any risk level) | Surgery cannot be delayed, whether or not the patient has fasted | Treat as a full stomach: decompress the stomach with a nasogastric or orogastric tube where possible, and use rapid sequence induction |
