Preprocedure Care of Patients on Glucagon-like Peptide-1 Receptor Agonists: A Multisociety Clinical Practice Guidance

There is an exponential increase in the use of glucagon-like peptide-1 receptor agonists (GLP-1RAs) in recent years due to their numerous clinical benefits.  However, GLP-1RAs delay gastric emptying with recent reports of aspiration of gastric contents during sedation and general anesthesia despite traditional, preoperative fasting requirements. The optimal approach to mitigation of aspiration risk remains controversial because of sparse and inconsistent evidence. In 2023, the American Society of Anesthesiologists (Schaumburg, Illinois) published guidance for management of patients on GLP-1RAs with the primary aim of informing clinicians and patients of the heightened risk of aspiration and emphasizing shared decision-making.  Subsequently, other professional societies have also published recommendations for perioperative or periprocedure management of patients on GLP-1RAs.

A multisociety consensus for the management of patients on GLP-1RAs was developed by representatives from the American Society of Anesthesiologists, the American Gastroenterological Association (Bethesda, Maryland), the American Society for Metabolic and Bariatric Surgery (Gainesville, Florida), the International Society of Perioperative Care of Patients with Obesity (Lynnwood, Washington), and the Society of American Gastrointestinal and Endoscopic Surgeons (Los Angeles, California).  This practice guidance emphasizes that the approach to managing patients on GLP-1RAs should be based on shared decision-making of the patient, the prescribing care team, the proceduralist or surgeon, and the anesthesiologist.  One of the first steps is preprocedure assessment of aspiration risk, performed with enough time in advance to identify patients at risk and allow for adjustments in periprocedural care if needed. Factors that may increase the risk of aspiration include the escalation phase of dosing, long-acting GLP-1RAs, higher doses, the presence of gastrointestinal symptoms of delayed gastric emptying (e.g., nausea, vomiting, and abdominal discomfort), and medical conditions other than GLP-1 RA usage that might delay gastric emptying. 

The multisociety clinical practice guidance suggests that patients without risk factors may continue GLP-1RA therapy as usual in the perioperative period. Bridging therapy is not a viable option for most patients. For patients identified with an increased risk profile, use of a liquid diet for at least 24 h before the procedure to decrease the risk of retained gastric contents on the day of the procedure (as usually performed in patients undergoing colonoscopy and bariatric surgery) allows for the continuation of GLP-1RA therapy in the perioperative period.  If an unacceptable safety profile exists to continue GLP-1RA, patients may be asked to withhold therapy; however, this should be balanced with the risk of inducing a metabolic disease state, like hyperglycemia, that may complicate postprocedure patient care. The duration of holding should follow the guidance of the American Society of Anesthesiologists consensus-based guidance (i.e., holding the day of surgery for daily formulations and a week before surgery for weekly formulations).

On the day of procedure, if GLP-1RAs are continued, patients should again be assessed for symptoms suggestive of delayed gastric emptying. A point-of-care gastric ultrasound could also be considered to assess for retained gastric contents but presents technical and logistical difficulty. For patients determined to be at higher risk of aspiration on the day of procedure, rapid sequence induction of general anesthesia may be considered, if appropriate. These recommendations apply to all patients receiving GLP-1RAs, irrespective of the indication for GLP-1RA therapy.

In summary (table 1), this multisociety consensus provides guidance for management of patients on GLP-1RAs; however, it is not an evidence-based guideline. This approach emphasizes shared decision-making and provides recommendations for balancing continuation of GLP-1RA therapy perioperatively for surgery and procedures while minimizing the risk of aspiration.