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Filipovic MG, Baettig SJ, Ganter MT, Asai T, Luedi MM. Diabetes mellitus and the risk of aspiration - Safe and (ultra)sound? J Clin Anesth 2024; 96:111396. [PMID: 38267325 DOI: 10.1016/j.jclinane.2024.111396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 01/13/2024] [Indexed: 01/26/2024]
Affiliation(s)
- Mark G Filipovic
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Sascha J Baettig
- Institute of Anaesthesiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michael T Ganter
- Institute of Anaesthesiology and Critical Care Medicine, Medical Faculty, Klinik Hirslanden Zurich, University of Zurich, Zurich, Switzerland
| | - Takashi Asai
- Department of Anesthesiology, Dokkyo Medical University, Koshigaya Hospital, 2-1-50 Minami-Koshigaya, Koshigaya, Saitama 343-8555, Japan
| | - Markus M Luedi
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Anesthesiology, Rescue and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
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2
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Ghazanfar H, Javed N, Qasim A, Sosa F, Altaf F, Khan S, Mahasamudram J, Jyala A, Kandhi SD, Shin D, Mantri N, Sun H, Hanumanthu S, Patel H, Makker J, Balar B, Dev A, Chilimuri S. Is it necessary to stop glucagon-like peptide-1 receptor agonists prior to endoscopic procedure? A retrospective study. World J Gastroenterol 2024; 30:3221-3228. [DOI: 10.3748/wjg.v30.i26.3221] [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: 03/26/2024] [Revised: 05/14/2024] [Accepted: 06/24/2024] [Indexed: 07/09/2024] Open
Abstract
BACKGROUND Glucagon-like peptide-1 receptor agonists (GLP-1 RA) are effective in diabetes and obesity, reducing hyperglycemia by increasing insulin release and delaying gastric emptying. However, they can cause gastroparesis, raising concerns about aspiration during procedures. Recent guidelines advise discontinuing GLP-1 RA before surgery to reduce the risk of pulmonary aspiration.
AIM To evaluate the effect of GLP-1 RAs on gastric residual contents during endoscopic procedures.
METHODS A retrospective chart review at BronxCare Health System, New York, from January 2019 to October 2023, assessed gastric residue and aspiration in GLP-1 RA patients undergoing endoscopic procedures. Two groups were compared based on dietary status before the procedure. Data included demographics, symptoms of gastroparesis, opiate use, hemoglobin A1c, GLP-1 agonist indication, endoscopic details, and aspiration occurrence. IBM SPSS was used for analysis, calculating means, standard deviations, and applying Pearson’s chi-square and t-tests for associations, with P < 0.05 as being significant.
RESULTS During the study, 306 patients were included, with 41.2% on a clear liquid/low residue diet and 58.8% on a regular diet before endoscopy. Most patients (63.1%) were male, with a mean age of 60 ± 12 years. The majority (85.6%) were on GLP-1 RAs for diabetes, and 10.1% reported digestive symptoms before endoscopy. Among those on a clear liquid diet, 1.5% had residual food at endoscopy compared to 10% on a regular diet, which was statistically significant (P = 0.03). Out of 31 patients with digestive symptoms, 13% had residual food, all from the regular diet group (P = 0.130). No complications were reported during or after the procedures.
CONCLUSION The study reflects a significant rise in GLP-1 RA use for diabetes and obesity. A 24-hour liquid diet seems safe for endoscopic procedures without aspiration. Patients with upper gastrointestinal symptoms might have a higher residual food risk, though not statistically significant. Further research is needed to assess risks based on diabetes duration, gastroparesis, and GLP-1 RA dosing, aiming to minimize interruptions in therapy during procedures.
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Affiliation(s)
- Haider Ghazanfar
- Division of Gastroenterology, Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, United States
| | - Nismat Javed
- Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, United States
| | - Abeer Qasim
- Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, United States
| | - Franklin Sosa
- Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, United States
| | - Faryal Altaf
- Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, United States
| | - Shazia Khan
- Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, United States
| | - Jaydeep Mahasamudram
- Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, United States
| | - Abhilasha Jyala
- Division of Gastroenterology, Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, United States
| | - Sameer Datta Kandhi
- Division of Gastroenterology, Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, United States
| | - Dongmin Shin
- Division of Gastroenterology, Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, United States
| | - Nikhitha Mantri
- Division of Gastroenterology, Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, United States
| | - Haozhe Sun
- Division of Gastroenterology, Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, United States
| | - Siddarth Hanumanthu
- Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, United States
| | - Harish Patel
- Division of Gastroenterology, Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, United States
| | - Jasbir Makker
- Division of Gastroenterology, Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, United States
| | - Bhavna Balar
- Division of Gastroenterology, Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, United States
| | - Anil Dev
- Division of Gastroenterology, Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, United States
| | - Sridhar Chilimuri
- Division of Gastroenterology, Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, United States
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Sotiriou A, El-Boghdadly K. Point-of-care gastric ultrasound: believing is seeing. Can J Anaesth 2024:10.1007/s12630-024-02778-2. [PMID: 38862867 DOI: 10.1007/s12630-024-02778-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 04/18/2024] [Accepted: 05/02/2024] [Indexed: 06/13/2024] Open
Affiliation(s)
- Andreas Sotiriou
- Department of Anaesthesia, University Hospital Lewisham, Lewisham and Greenwich NHS, London, UK
| | - Kariem El-Boghdadly
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.
- King's College London, London, UK.
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4
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Welk B, McClure JA, Carter B, Clarke C, Dubois L, Clemens KK. No association between semaglutide and postoperative pneumonia in people with diabetes undergoing elective surgery. Diabetes Obes Metab 2024. [PMID: 38860419 DOI: 10.1111/dom.15711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 05/24/2024] [Accepted: 05/24/2024] [Indexed: 06/12/2024]
Affiliation(s)
- Blayne Welk
- Department of Surgery, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | | | | | - Collin Clarke
- Department of Anesthesia, Western University, London, Ontario, Canada
| | - Luc Dubois
- Department of Surgery, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Kristin K Clemens
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Medicine, Western University, London, Ontario, Canada
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5
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Wu F, Klapman SA, Everett LL, Kuo B, Hobai IA. GLP-1 receptor agonist tachyphylaxis and perioperative recommendations. Br J Anaesth 2024:S0007-0912(24)00268-X. [PMID: 38834487 DOI: 10.1016/j.bja.2024.04.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 04/02/2024] [Accepted: 04/26/2024] [Indexed: 06/06/2024] Open
Affiliation(s)
- Fei Wu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Seth A Klapman
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Lucinda L Everett
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Braden Kuo
- Division of Gastroenterology, Department of Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Ion A Hobai
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.
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Arora L, Sharma S, Carillo JF. Obesity and anesthesia. Curr Opin Anaesthesiol 2024; 37:299-307. [PMID: 38573180 DOI: 10.1097/aco.0000000000001377] [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: 04/05/2024]
Abstract
PURPOSE OF REVIEW Surgical procedures on obese patients are dramatically increasing worldwide over the past few years. In this review, we discuss the physiopathology of predominantly respiratory system in obese patients, the importance of preoperative evaluation, preoxygenation and intraoperative positive end expiratory pressure (PEEP) titration to prevent pulmonary complications and the optimization of airway management and oxygenation to reduce or prevent postoperative respiratory complications. RECENT FINDINGS Many patients are coming to preoperative clinic with medication history of glucagon-like-peptide 1 agonists ( GLP-1) agonists and it has raised many questions regarding Nil Per Os (NPO)/perioperative fasting guidelines due to delayed gastric emptying caused by these medications. American Society of Anesthesiologists (ASA) has come up with guiding document to help with such situations. Ambulatory surgery centers are doing more obesity cases in a safe manner which were deemed unsafe at one point . Quantitative train of four (TOF) monitoring, better neuromuscular reversal agents and gastric ultrasounds seemed to have made a significant impact in the care of obese patients in the perioperative period. SUMMARY Obese patients are at higher risk of perioperative complications, mainly associated with those related to the respiratory function. An appropriate preoperative evaluation, intraoperative management, and postoperative support and monitoring is essential to improve outcome and increase the safety of the surgical procedure.
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Affiliation(s)
- Lovkesh Arora
- Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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7
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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.
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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
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8
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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.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Sen S, Potnuru PP, Hernandez N, Goehl C, Praestholm C, Sridhar S, Nwokolo OO. Glucagon-Like Peptide-1 Receptor Agonist Use and Residual Gastric Content Before Anesthesia. JAMA Surg 2024; 159:660-667. [PMID: 38446466 PMCID: PMC10918573 DOI: 10.1001/jamasurg.2024.0111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 12/31/2023] [Indexed: 03/07/2024]
Abstract
Importance Glucagon-like peptide-1 receptor agonist (GLP-1 RA) use is rapidly increasing in the US, driven by its expanded approval for weight management in addition to hyperglycemia management in patients with type 2 diabetes. The perioperative safety of these medications, particularly with aspiration risk under anesthesia, is uncertain. Objective To assess the association between GLP-1 RA use and prevalence of increased residual gastric content (RGC), a major risk factor for aspiration under anesthesia, using gastric ultrasonography. Design, Setting, and Participants This cross-sectional study prospectively enrolled patients from a large, tertiary, university-affiliated hospital from June 6 through July 12, 2023. Participants followed preprocedural fasting guidelines before an elective procedure under anesthesia. Patients with altered gastric anatomy (eg, from previous gastric surgery), pregnancy, recent trauma (<1 month), or an inability to lie in the right lateral decubitus position for gastric ultrasonography were excluded. Exposure Use of a once-weekly GLP-1 RA. Main Outcomes and Measures The primary outcome was the presence of increased RGC, defined by the presence of solids, thick liquids, or more than 1.5 mL/kg of clear liquids on gastric ultrasonography. Analysis was adjusted for confounders using augmented inverse probability of treatment weighting, a propensity score-based technique. Secondarily, the association between the duration of drug interruption and the prevalence of increased RGC was explored. Results Among the 124 participants (median age, 56 years [IQR, 46-65 years]; 75 [60%] female), the prevalence of increased RGC was 56% (35 of 62) in patients with GLP-1 RA use (exposure group) compared with 19% (12 of 62) in patients who were not taking a GLP-1 RA drug (control group). After adjustment for confounding, GLP-1 RA use was associated with a 30.5% (95% CI, 9.9%-51.2%) higher prevalence of increased RGC (adjusted prevalence ratio, 2.48; 95% CI, 1.23-4.97). There was no association between the duration of GLP-1 RA interruption and the prevalence of increased RGC (adjusted odds ratio, 0.86; 95% CI, 0.65-1.14). Conclusions and Relevance Use of a GLP-1 RA was independently associated with increased RGC on preprocedural gastric ultrasonography. The findings suggest that the preprocedural fasting duration suggested by current guidelines may be inadequate in this group of patients at increased risk of aspiration under anesthesia.
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Affiliation(s)
- Sudipta Sen
- Department of Anesthesiology, Critical Care and Pain Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Paul P. Potnuru
- Department of Anesthesiology, Critical Care and Pain Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Nadia Hernandez
- Department of Anesthesiology, Critical Care and Pain Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Christina Goehl
- Department of Anesthesiology, Critical Care and Pain Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Caroline Praestholm
- McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Srikanth Sridhar
- Department of Anesthesiology, Critical Care and Pain Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Omonele O. Nwokolo
- Department of Anesthesiology, Critical Care and Pain Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston
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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.
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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.
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Barlowe TS, Anderson C, Sandler RS, Subramaniam D, Muratore A, Buse JB, Gouker LN, Majithia RT, Shaheen NJ, Stürmer T, Dougherty MK. Glucagon-Like Peptide-1 Receptor Agonists Do Not Increase Aspiration During Upper Endoscopy in Patients With Diabetes. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00453-1. [PMID: 38759826 DOI: 10.1016/j.cgh.2024.04.038] [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: 04/03/2024] [Accepted: 04/15/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND & AIMS Glucagon-like peptide-1-receptor agonists (GLP1-RAs) have been associated with greater retention of gastric contents, however, there is minimal controlled, population-based data evaluating the potential adverse effects of GLP1-RA in the periprocedural setting. We aimed to determine if there is increased risk of aspiration and aspiration-related complications after upper endoscopy in patients using GLP1-RAs. METHODS We used a nationwide commercial administrative claims database to conduct a retrospective cohort study of patients aged 18 to 64 with type 2 diabetes who underwent outpatient upper endoscopy from 2005 to 2021. We identified 6,806,046 unique upper endoscopy procedures. We compared claims for aspiration and associated pulmonary adverse events in the 14 days after upper endoscopy between users of GLP1-RAs, dipeptidyl peptidase 4 inhibitors (DPP4is), and chronic opioids. We adjusted for age, sex, Charlson Comorbidity score, underlying respiratory disease, and gastroparesis. RESULTS We found that pulmonary adverse events after upper endoscopy are rare, ranging from 6 to 25 events per 10,000 procedures. When comparing GLP1-RAs with DPP4i, crude relative risks of aspiration (0.67; 95% CI, 0.25-1.75), aspiration pneumonia (0.95; 95% CI, 0.40-2.29), pneumonia (1.07; 95% CI, 0.62-1.86), or respiratory failure (0.75; 95% CI, 0.38-1.48) were not higher in patients prescribed a GLP1-RA. When comparing GLP1-RAs with opioids, crude relative risks were 0.42 (95% CI, 0.15-1.16) for aspiration, 0.60 (95% CI, 0.24-1.52) for aspiration pneumonia, 0.30 (95% CI, 0.19-0.49) for pneumonia, and 0.24 (95% CI, 0.13-0.45) for respiratory failure. These results were consistent across several sensitivity analyses. CONCLUSIONS GLP1-RA use is not associated with an increased risk of pulmonary complications after upper endoscopy compared with DPP4i use in patients with type 2 diabetes.
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Affiliation(s)
- Trevor S Barlowe
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina.
| | - Chelsea Anderson
- Center for Gastrointestinal Biology and Disease, Chapel Hill, North Carolina
| | - Robert S Sandler
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, Chapel Hill, North Carolina
| | - Disha Subramaniam
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Alicia Muratore
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - John B Buse
- Division of Endocrinology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Lindsey N Gouker
- Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina
| | | | - Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, Chapel Hill, North Carolina
| | - Til Stürmer
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Michael K Dougherty
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina; UNC Rex Digestive Healthcare, Raleigh, North Carolina.
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Firkins SA, Yates J, Shukla N, Garg R, Vargo JJ, Lembo A. Clinical Outcomes and Safety of Upper Endoscopy While on Glucagon-Like Peptide-1 Receptor Agonists. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00295-7. [PMID: 38574832 DOI: 10.1016/j.cgh.2024.03.013] [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] [Received: 01/10/2024] [Revised: 03/10/2024] [Accepted: 03/11/2024] [Indexed: 04/06/2024]
Abstract
Glucose-like peptide-1-receptor agonists (GLP-1RAs) have become integral to the management of type 2 diabetes and obesity. GLP-1RAs work in part through delaying gastric emptying, raising concerns about retained gastric contents (RGC) during esophagogastroduodenoscopy (EGD).1 The American Society of Anesthesiologists currently recommends holding GLP-1RAs for 1 dosing cycle before elective procedures, however, the American Gastroenterological Association (AGA) advocates proceeding with endoscopy in asymptomatic patients adhering to standard perioperative protocols without medication withholding and suggests implementing a liquid diet the day before endoscopy in lieu of stopping the medication.2,3 This variability in recommendations stems largely from a lack of GLP-1RA outcomes data from which to draw evidence-based conclusions.
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Affiliation(s)
- Stephen A Firkins
- Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Joy Yates
- Community Care Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Neehal Shukla
- Community Care Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Rajat Garg
- Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - John J Vargo
- Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Anthony Lembo
- Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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Willson CM, Patel L, Middleton P, Desai M. Glucagon-Like Peptide-1 Agonists and General Anesthesia: Perioperative Considerations and the Utility of Gastric Ultrasound. Cureus 2024; 16:e58042. [PMID: 38738030 PMCID: PMC11088359 DOI: 10.7759/cureus.58042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2024] [Indexed: 05/14/2024] Open
Abstract
Glucagon-like peptide-1 (GLP-1) agonists are very popular and useful medications for the treatment of type 2 diabetes mellitus and obesity. Potent gastric emptying delay is common with these medications, serving as a major contributor to the postprandial glycemic control and weight loss benefits of these medications. Recently, multiple case reports and studies indicating safety risks for these medications and their use in patients planning to undergo general anesthesia have been published, as retained gastric contents can lead to intraoperative aspiration. New guidelines for these medications have been released to guide clinical practice for anesthesiologists. Some degree of preoperative cessation of these medications is required. At this time, the ideal window for cessation of these medications to optimize clinical efficacy while reducing aspiration risks has not yet been well elaborated on. Aspiration of gastric contents can still occur despite appropriate preoperative fasting in patients taking GLP-1 agonists. Gastric ultrasound appears to be an effective and objective way of preoperatively assessing a patient's stomach contents to make decisions regarding anesthetic management for patients prescribed these medications. This practice is limited by a general lack of training and implementation in current anesthesiology practice.
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Affiliation(s)
- Conner M Willson
- Department of Clinical Medicine, Des Moines University, Des Moines, USA
| | - Love Patel
- Department of Clinical Medicine, Des Moines University, Des Moines, USA
| | - Peter Middleton
- Department of Clinical Medicine, Des Moines University, Des Moines, USA
| | - Mihir Desai
- Department of Anesthesiology, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
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14
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Hashash JG, Thompson CC, Wang AY. AGA Rapid Clinical Practice Update on the Management of Patients Taking GLP-1 Receptor Agonists Prior to Endoscopy: Communication. Clin Gastroenterol Hepatol 2024; 22:705-707. [PMID: 37944573 DOI: 10.1016/j.cgh.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 11/12/2023]
Abstract
DESCRIPTION The purpose of this American Gastroenterological Association (AGA) Institute Rapid Clinical Practice Update (CPU) Communication is to review the available evidence and provide expert advice regarding the evolving management of patients taking GLP-1 receptor agonists prior to endoscopy. METHODS This CPU was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPUC and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. This communication incorporates important and recently published studies in this field, and it reflects the experiences of the authors who are experts in bariatric medicine and/or endoscopy.
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Affiliation(s)
- Jana G Hashash
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia.
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15
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Umpierrez G, Pasquel FJ, Duggan E, Galindo RJ. Should We Stop Glucagon-Like Peptide-1 Receptor Agonists Before Surgical or Endoscopic Procedures? Balancing Limited Evidence With Clinical Judgment. J Diabetes Sci Technol 2024:19322968241231565. [PMID: 38465586 DOI: 10.1177/19322968241231565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
The American Society of Anesthesiologists (ASA) Task Force recently recommended discontinuing glucagon-like peptide-1 receptor agonist (GLP-1 RA) agents before surgery because of the potential risk of pulmonary aspiration. However, there is limited scientific evidence to support this recommendation, and holding GLP-1 RA treatment may worsen glycemic control in patients with diabetes. As we await further safety data to manage GLP-1 RA in the perioperative period, we suggest an alternative multidisciplinary approach to manage patients undergoing elective surgery. Well-conducted observational and prospective studies are needed to determine the risk of pulmonary aspiration in persons receiving GLP-1 RA for the treatment of diabetes and obesity, as well as the short-term impact of discontinuing GLP-1 RA on glycemic control before elective procedures in persons with diabetes.
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Affiliation(s)
- Guillermo Umpierrez
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Francisco J Pasquel
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Elizabeth Duggan
- Department of Anesthesiology and Perioperative Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rodolfo J Galindo
- Division of Endocrinology, Department of Medicine, University of Miami, Miami, FL, USA
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16
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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)
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17
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Hodgson JA, Rivera-Rodriguez H, Wu P, Udani J, Weiss J. Point-of-Care Ultrasound Aids in the Management of Patient Taking Semaglutide Before Surgery: A Case Report. A A Pract 2024; 18:e01762. [PMID: 38498670 DOI: 10.1213/xaa.0000000000001762] [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: 03/20/2024]
Abstract
Semaglutide, a glucagon-like peptide-1 (GLP-1) analog, has various effects on the gastrointestinal tract. In patients undergoing anesthesia delayed gastric emptying time can have sequelae if not identified preoperatively. Modalities include thorough history regarding the last dose administration of a GLP-1 analog and ultrasound of gastric contents before induction of anesthesia. We present a case in which gastric ultrasound identified a patient at increased risk for aspiration on induction and allowed for appropriate alterations in the anesthetic plan.
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Affiliation(s)
- John A Hodgson
- From the Department of Anesthesiology, Tampa General Hospital, Tampa, Florida
| | | | - Peter Wu
- From the Department of Anesthesiology, Tampa General Hospital, Tampa, Florida
- Department of Medical Education, University of South Florida, Tampa Florida
| | - Jaison Udani
- From the Department of Anesthesiology, Tampa General Hospital, Tampa, Florida
| | - Jeffrey Weiss
- From the Department of Anesthesiology, Tampa General Hospital, Tampa, Florida
- Department of Medical Education, University of South Florida, Tampa Florida
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18
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Espinoza RT, Antongiorgi Z. Glucagon-Like Peptide-1 Receptor Agonists During Electroconvulsive Therapy: Case Report With Evolving Concerns and Management Considerations. J ECT 2024:00124509-990000000-00141. [PMID: 38315827 DOI: 10.1097/yct.0000000000000992] [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: 02/07/2024]
Abstract
ABSTRACT Glucagon-like peptide-1 receptor agonists are an emerging class of medications transforming the management of diabetes mellitus and obesity, two highly prevalent and chronic medical conditions associated with significant morbidity and posing serious public health concerns. Although generally well tolerated and relatively safe to use, case reports of patients taking these medications while undergoing elective procedures with general anesthesia describe a potential heightened risk of regurgitation and pulmonary aspiration of gastric contents, deriving from the delayed gastric emptying effect of these agents. Based on increased recognition of this risk, the American Society of Anesthesiologists convened a task force to review available data, resulting in the promulgation of a new procedural management guideline for patients on these drugs and undergoing elective procedures with general anesthesia. However, this guideline pertains mostly to procedures and situations that are distinct from electroconvulsive therapy (ECT). This case report describes the experience of a patient on semaglutide, a glucagon-like peptide-1 receptor agonist for obesity, undergoing ECT, provides a general overview of this novel drug class, identifies issues specific to ECT management, and suggests potential adaptations to patient care over different phases of ECT practice.
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Affiliation(s)
| | - Zarah Antongiorgi
- Department of Anesthesiology and Perioperative Medicine, Geffen School of Medicine at UCLA, Los Angeles, CA
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19
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Casazza JA, Kacker A. Semaglutide in Patients Undergoing Anesthesia for Otolaryngologic Procedures. Laryngoscope 2024; 134:543-544. [PMID: 38038217 DOI: 10.1002/lary.31214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/25/2023] [Accepted: 11/22/2023] [Indexed: 12/02/2023]
Affiliation(s)
- Julia A Casazza
- Medical School, UT Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Ashutosh Kacker
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical Center, New York, New York, U.S.A
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20
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Lupianez-Merly C, Dilmaghani S, Vosoughi K, Camilleri M. Review article: Pharmacologic management of obesity - updates on approved medications, indications and risks. Aliment Pharmacol Ther 2024; 59:475-491. [PMID: 38169126 DOI: 10.1111/apt.17856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Obesity has reached epidemic proportions, with >40% of the US population affected. Although traditionally managed by lifestyle modification, and less frequently by bariatric therapies, there are significant pharmacological advancements. AIMS To conduct a narrative review of the neurohormonal and physiological understanding of weight gain and obesity, and the development, clinical testing, indications, expected clinical outcomes, and associated risks of current FDA-approved and upcoming anti-obesity medications (AOMs). METHODS We conducted a comprehensive review in PubMed for articles on pathophysiology and complications of obesity, including terms 'neurohormonal', 'obesity', 'incretin', and 'weight loss'. Next, we searched for clinical trial data of all FDA-approved AOMs, including both the generic and trade names of orlistat, phentermine/topiramate, bupropion/naltrexone, liraglutide, and semaglutide. Additional searches were conducted for tirzepatide and retatrutide - medications expecting regulatory approval. Searches included combinations of terms related to mechanism of action, indications, side effects, risks, and future directions. RESULTS We reviewed the pathophysiology of obesity, including specific role of incretins and glucagon. Clinical data supporting the use of various FDA-approved medications for weight loss are presented, including placebo-controlled or, when available, head-to-head trials. Beneficial metabolic effects, including impact on liver disease, adverse effects and risks of medications are discussed, including altered gastrointestinal motility and risk for periprocedural aspiration. CONCLUSION AOMs have established efficacy and effectiveness for weight loss even beyond 52 weeks. Further pharmacological options, such as dual and triple incretins, are probable forthcoming additions to clinical practice for combating obesity and its metabolic consequences such as metabolic dysfunction-associated steatotic liver disease.
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Affiliation(s)
- Camille Lupianez-Merly
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Saam Dilmaghani
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kia Vosoughi
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Massey BT. GORD and GLP-1 receptor agonists: an emerging concern for gastroenterologists. Gut 2024; 73:211-212. [PMID: 37918890 DOI: 10.1136/gutjnl-2023-331027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 10/23/2023] [Indexed: 11/04/2023]
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Joshi GP. Anesthetic Considerations in Adult Patients on Glucagon-Like Peptide-1 Receptor Agonists: Gastrointestinal Focus. Anesth Analg 2024; 138:216-220. [PMID: 37874648 DOI: 10.1213/ane.0000000000006810] [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: 10/26/2023]
Affiliation(s)
- Girish P Joshi
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
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23
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Jones PM, Hobai IA, Murphy PM. Anesthesia and glucagon-like peptide-1 receptor agonists: proceed with caution! Can J Anaesth 2023; 70:1281-1286. [PMID: 37466910 DOI: 10.1007/s12630-023-02550-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 06/23/2023] [Accepted: 06/23/2023] [Indexed: 07/20/2023] Open
Affiliation(s)
- Philip M Jones
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
| | - Ion A Hobai
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Patricia M Murphy
- Department of Anesthesiology and Pain Medicine, Toronto General Hospital, University Health Network, Toronto, ON, Canada
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