Relationship between perioperative semaglutide use and residual gastric content: A retrospective analysis of patients undergoing elective upper endoscopy

Association of semaglutide with retained gastric contents on endoscopy: Retrospective analysis

Background and study aims

We investigated the effect of semaglutide, a glucagon-like peptide-1 (GLP-1) agonist therapy, on retained gastric contents during endoscopy through a retrospective case-control study.

Patients and methods

We performed a retrospective case-control study to evaluate the effect of semaglutide on rates of retained gastric contents (RGC) visualized during esophagogastroduodenoscopy (EGD). Cases and controls were matched using multidimensional propensity score matching: age, gender, body mass index, and EGD indication. Pairs were analyzed using McNemar testing and Mann-Whitney non-parametric tests.

Results

Of the patients on GLP-1 therapy at time of EGD, 12.5% had RGC, compared with 1.3% in the control group (confidence interval [CI] 7.2% to 17.7%, P < 0.0001). Approximately 23% of patients prescribed GLP-1 therapy for weight loss had RGC at time of EGD compared with the control group (CI 13.4% to 32.6%, P < 0.0001). Only 2.6% of patients prescribed GLP-1 therapy for diabetes had RGC at time of EGD compared with the control group (CI -0.9% to 6.1%, P = 0.5). Patients receiving GLP-1 therapy with RGC at time of EGD did not differ from non-RGC patients in dosing of GLP-1 agonist ( P = 0.23) or duration of GLP-1 agonist use prior to EGD ( P = 0.98).

Conclusions

Semaglutide use appears to increase risk of having retained gastric contents visualized during endoscopy. Patients on semaglutide for weight loss appear to have a greater risk of RGC compared with patients on semaglutide for glycemic control. This observation may have clinical implications for management of GLP-1 agonist use prior to endoscopy.

Comparing the risk of gastroparesis following different modalities for treating obesity: semaglutide versus bupropion-naltrexone versus sleeve gastrectomy - a retrospective cohort study

OBJECTIVE

The use of glucagon-like peptide 1 receptor agonists has been associated with gastroparesis, but little is known about the risk of gastroparesis in those with obesity but without type 2 diabetes (T2D), and how that risk compares with other treatment modalities for obesity. This study aims to characterise the relationship between different treatment modalities for obesity and the risk of gastroparesis in a population without pre-existing T2D.

METHODS

A retrospective cohort study using Merative MarketScan Research Databases of individuals with obesity who underwent treatment with semaglutide, bupropion-naltrexone or sleeve gastrectomy from 1 January 2018 to 31 December 2022. The incidence of gastroparesis diagnosis was evaluated using International Classification of Diseases, Version 10 codes. The risk of gastroparesis was compared between three intervention groups using Cox proportional hazards regression models.

RESULTS

Of the 55 460 individuals included, 36 990 (66.7%) were treated with semaglutide, 7369 (13.3%) with bupropion-naltrexone and 11 101 (13.7%) with sleeve gastrectomy. Gastroparesis rates among those treated with semaglutide versus bupropion-naltrexone versus sleeve gastrectomy were 6.5 per 1000 person-years (PY) vs 2.1 per 1000 PY vs 1.1 per 1000 PY, respectively. After adjusting for baseline characteristics, individuals treated with semaglutide had a higher risk of gastroparesis than those treated with bupropion-naltrexone (adjusted HR 3.33, 95% CI 2.27, 4.98) and sleeve gastrectomy (adjusted HR 6.14, 95% CI 3.94, 9.57).

CONCLUSIONS

There is an increased incidence of gastroparesis among individuals with obesity without T2D who are using semaglutide as compared with bupropion-naltrexone and sleeve gastrectomy. Understanding these potential side effects, though rare, may help guide personalised treatment regimens.

Elective peri-operative management of adults taking glucagon-like peptide-1 receptor agonists, glucose-dependent insulinotropic peptide agonists and sodium-glucose cotransporter-2 inhibitors: a multidisciplinary consensus statement: A consensus statement from the Association of Anaesthetists, Association of British Clinical Diabetologists, British Obesity and Metabolic Surgery Society, Centre for Perioperative Care, Joint British Diabetes Societies for Inpatient Care, Royal College of Anaesthetists, Society for Obesity and Bariatric Anaesthesia and UK Clinical Pharmacy Association

INTRODUCTION

Glucagon-like peptide-1 receptor agonists, dual glucose-dependent insulinotropic peptide receptor agonists and sodium-glucose cotransporter-2 inhibitors are used increasingly in patients receiving peri-operative care. These drugs may be associated with risks of peri-operative pulmonary aspiration or euglycaemic ketoacidosis. We produced a consensus statement for the peri-operative management of adults taking these drugs.

METHODS

This multidisciplinary consensus statement included surgeons, anaesthetists, physicians, pharmacists and people with lived experience relevant to these guidelines. Following the directed literature review, a three-round modified Delphi process was conducted to generate and ratify recommendations.

RESULTS

Patients taking glucagon-like peptide-1 receptor agonists and dual glucose-dependent insulinotropic peptide receptor agonists should: continue these drugs before surgery; have full risk assessment and stratification; and receive peri-operative techniques that may mitigate risk of pulmonary aspiration before, during and after sedation or general anaesthesia. Patients taking sodium-glucose cotransporter-2 inhibitors should omit them the day before and the day of a procedure. All patients should have risks and mitigation strategies discussed with a shared decision-making approach.

DISCUSSION

Until more evidence becomes available, this pragmatic, multidisciplinary consensus statement aims to support shared decision-making and improve safety for patients taking glucagon-like peptide-1 receptor agonists, dual glucose-dependent insulinotropic peptide receptor agonists and sodium-glucose cotransporter-2 inhibitors during the peri-operative period.

Glucagon-like peptide-1 receptor agonist use and the risk of residual gastric contents and aspiration in patients undergoing GI endoscopy: a systematic review and a meta-analysis

BACKGROUND AND AIMS

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are used for type 2 diabetes mellitus and obesity, but safety concerns have been raised for users undergoing GI endoscopy because of retained food and aspiration events. We compared the risk of adverse events for GLP-1RA users and nonusers undergoing endoscopy.

METHODS

We conducted a systematic review and meta-analysis (PROSPERO registration: CRD42024556732). A systematic search in PubMed, Scopus, Web of Science, and Cochrane Central was performed from their inception until July 1, 2024 (EMBASE from 1974 to June 28, 2024). Double-arm adult human original studies (observational, randomized controlled trial) with a sample size of ≥20 undergoing EGD or endoscopy with no GLP-1RA use in the control arm were searched. Studies were excluded if they were single arm and had any use of GLP-1RA before the procedure in the control arm. Residual gastric contents (RGCs), aspiration pneumonia, and premature endoscopy termination were the main outcomes. The random-effects model was used to pool and get final effect estimates.

RESULTS

Twenty-three observational studies were selected consisting of 262,018 patients. GLP-1RA users had a statistically significant increase in the risk of RGCs (odds ratio [OR], 4.54; 95% confidence interval [CI], 3.30-6.24; P < .00001, I2 = 68%) and premature endoscopy termination (OR, 4.54; 95% CI, 3.05-6.75; P < .00001, I2 = 0%). There was no significant difference in the risk of aspiration pneumonia (OR, .96; 95% CI, .53-1.75; P = .90, I2 = 70%). A significant reduction was seen in RGCs when EGD and colonoscopy (OR, .28; 95% CI, .22-.36; P < .00001, I2 = 0%) were done the same day versus EGD alone.

CONCLUSIONS

GLP-1RA use was associated with an increased risk of RGCs and premature endoscopy termination, but no significant difference was found in the risk of aspiration pneumonia in patients undergoing endoscopy.

Clinical Outcomes and Safety of Upper Endoscopy While on Glucagon-Like Peptide-1 Receptor Agonists

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.

SAFE anaesthesia for patients at risk of pulmonary aspiration: A nationwide survey

BACKGROUND

Clinical practice in patients at risk of pulmonary aspiration varies widely. However, data on actual management, decision-driving factors and controversial issues remain elusive.

OBJECTIVE

We aimed to comprehensively review the management of patients at risk of pulmonary aspiration and identify controversies among anaesthesia professionals.

DESIGN

National interprofessional survey.

SETTING

All anaesthesia departments in Switzerland.

PARTICIPANTS

The survey was distributed electronically to all members of the Swiss Society of Anaesthesiology and Perioperative Medicine, members of the Swiss Interest Group for Anaesthesia Nursing and all department heads in Switzerland.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Consensus and controversies in clinical practice and management of patients at risk of pulmonary aspiration.

RESULTS

A total of 684 respondents were included in the final analysis (59 department heads, 366 consultants, 99 registrars, 160 nurse anaesthetists). The response rate from physicians was 47%. Consensus (>80% agreement or disagreement) was reached on 9/12 (75%) questions regarding preparation for rapid sequence induction (RSI), 6/13 (46%) regarding RSI practice and 3/8 (38%) regarding management of aspiration incidents. Major controversies included high-flow pre-oxygenation (55% agreement), the validity of modified RSI in adults (52% agreement), the primary use of video-laryngoscope (76% agreement) and management of apparent regurgitation. Subjective factors such as clinical presentation were considered more important than objective factors such as medical history, comorbidities or gastric ultrasound.

CONCLUSION

Across a wide range of experience and professional groups, we found a strong consensus on the indication and performance of 'traditional' RSI. However, clinical decision-making still relies heavily on subjective impressions, while newer risk stratification and management techniques remain controversial.

Association of Perioperative Glucagon-like Peptide-1 Receptor Agonist Use and Postoperative Outcomes

OBJECTIVE

To assess rates of surgical complications and postoperative readmission in diabetic patients with and without active perioperative prescriptions for glucagon-like peptide-1 receptor agonist (GLP-1 RA) medications.

BACKGROUND

With the rapid growth of GLP-1 RA use in the United States, it is important to understand the potential effect of these drugs on surgical outcomes broadly.

METHODS

In this retrospective, observational cohort analysis, patients with a diagnosis of type 1 or type 2 diabetes undergoing a surgical procedure at a multicenter quaternary-care health care system between February 2020 and July 2023 were included. Propensity score matching was performed between procedures in patients with and without an active GLP-1 RA prescription. The primary outcome was 30-day readmission, and secondary outcomes were documented dehiscence, infection, hematoma, and bleeding within 180 days after surgery.

RESULTS

Among 74,425 surgical procedures in 21,772 patients included in the analysis, 27.2% were performed in the setting of an active GLP-1 RA prescription. In 13,129 patients [48.0% men, 52.0% women; median (interquartile range) age, 67 (57, 75)], 35,020 procedures were propensity score matched. After matching, the active GLP-1 RA prescription group had a significantly reduced risk of 30-day readmission [relative risk (RR): 0.883; 95% CI: 0.789-0.987; P = 0.028; number needed to treat (NNT): 219; 95% CI: 191-257], postoperative wound dehiscence (RR: 0.711; 95% CI: 0.577-0.877; P = 0.001; NNT: 266; 95% CI: 202-391), and postoperative hematoma (RR: 0.440; 95% CI: 0.216-0.894; P = 0.023; NNT: 1786; 95% CI: 652-2416). No significant differences were seen in rates of infection and bleeding.

CONCLUSIONS

An active perioperative GLP-1 RA prescription in patients with diabetes was associated with significant reductions in risk-adjusted readmission, wound dehiscence, and hematoma, and no difference in infection and bleeding rates. Further study is warranted to elucidate any causal association.

Effects of Glucagon-Like Peptide-1 Receptor Agonists on Upper Gastrointestinal Endoscopy: A Meta-Analysis

BACKGROUND AND AIMS

Limited evidence exists regarding the impact of glucagon-like peptide-1 receptor agonists (GLP-1RAs) on upper endoscopy. Therefore, a meta-analysis was conducted to comprehensively review the available evidence on this subject.

METHODS

A systematic bibliographic search was carried out until May 2024. Pooled estimates were analyzed using a random-effects model, with results presented as odds ratio (OR) and 95% confidence interval (CI). The primary outcome assessed was the rate of retained gastric content (RGC), while secondary outcomes included rates of aborted and repeated procedures, adverse event rate, and rates of aspiration.

RESULTS

This analysis included 13 studies involving a total of 84,065 patients. Patients receiving GLP-1RA therapy exhibited significantly higher rates of RGC (OR, 5.56; 95% CI, 3.35 to 9.23), a trend that was consistent among patients with diabetes (OR, 2.60; 95% CI, 2.23 to 3.02). Adjusted analysis, accounting for variables such as sex, age, body mass index, diabetes, and other therapies, confirmed the elevated rates of RGC in the GLP-1RA user group (adjusted OR, 4.20; 95% CI, 3.42 to 5.15). Furthermore, rates of aborted and repeated procedures were higher in the GLP-1RA user group (OR, 5.13; 95% CI, 3.01 to 8.75; and OR, 2.19; 95% CI, 1.43 to 3.35; respectively). However, no significant differences were found in AE and aspiration rates between the 2 groups (OR, 4.04; 95% CI, 0.63 to 26.03; and OR, 1.75; 95% CI, 0.64 to 4.77; respectively).

CONCLUSION

Use of GLP-1RAs is associated with increased retention of gastric contents and more frequent aborted procedures during upper endoscopy. However, the adverse event and aspiration rates do not seem different; therefore, adjusting fasting time instead of routinely withholding GLP-1RAs could be reasonable in these patients.

Glucagon-Like Peptide-1 Receptor Agonists Do Not Increase Aspiration During Upper Endoscopy in Patients With Diabetes

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.

A narrative review of glucagon-like peptide-1 receptor agonists prior to deep sedation or general anesthesia

Glucagon-like peptide-1 receptor agonists are a class of drugs that mimic a natural incretin hormone released by the intestine after meals, and they are well-suited for treating type 2 diabetes. Glucagon-like peptide-1 receptor agonists also lead to satiety and appetite reduction through action on the brain's appetite regulation centers, leading to weight loss in obese patients. However, because glucagon-like peptide-1 receptor agonists work to slow gastric emptying, a safety concern has been raised in patients undergoing deep sedation or general anesthesia regarding gastric aspiration, and considering their long half-life in the blood, they are difficult to manage in the perioperative period. The purpose of this review is (i) to explore the present knowledge about the risk of aspiration before anesthesia; (ii) to describe the method for evaluating the presence of liquid and food in the stomach before surgery; and (iii) to balance the actual warning with the opportunity for future discovery about their benefits.

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.

Glucagon-like peptide-1 receptor agonists increase the risk of residual gastric content and pulmonary aspiration on upper endoscopy: A meta-analysis

BACKGROUND AND AIMS

Glucagon-like peptide-1 receptor agonists (GLP1-RA) are associated with increased residual gastric content (RGC); however, there is debate about their impact on RGC-related clinical outcomes, particularly aspiration.

METHODS

PubMed, Embase, Web of Science and Cochrane Library databases were systematically searched for studies published up to January 4, 2025, comparing GLP1-RA with control groups (non-GLP1-RA) in patients undergoing endoscopy. The outcomes of interest included the risk of RGC, pulmonary aspiration, interrupted and repeated endoscopic procedures, and delays in gastric transit time during capsule endoscopy. For the meta-analysis, a random-effects model was used to calculate the pooled odds ratio (OR) and mean difference (MD) with 95 % confidence intervals (CIs).

RESULTS

Thirty-nine studies composed of a total of 1,253,498 subjects, were included. The pooled analysis demonstrated that the GLP1-RA group had a significantly increased risk of RGC (OR 4.86, 95 % CI 3.85-6.14; adjusted OR 5.24, 95 % CI 3.49-7.87), pulmonary aspiration (OR 2.29, 95 % CI 1.36-3.87), interrupted endoscopic procedures (OR 3.22, 95 % CI 1.65-6.29), repeated endoscopy (OR 2.16, 95 % CI 1.14-4.11), and delays in gastric transit time during capsule endoscopy (MD 45.51, 95 % CI 1.33-89.68).

CONCLUSIONS

GLP1-RA use increased the risk of RGC, pulmonary aspiration, interrupted and repeated endoscopy and gastric transit time, reducing the safety and completion of upper endoscopy.

Evidence Report on the Safety of Gastrointestinal Endoscopy in Patients on Glucagon-like Peptide-1 Receptor Agonists: A Systematic Review and Meta-Analysis

Background/Objectives: Glucagon-like peptide-1 receptor agonists are increasingly used worldwide for weight and hyperglycemia management. There is an ongoing debate on the presence of increased gastric residue, leading to complications such as aspiration and overall safety in patients receiving upper gastrointestinal endoscopy. We aimed to study the effect of GLP-RAs on endoscopy outcomes. Methods: We conducted a detailed search of online databases to select the studies which provided details of the effects of GLP-RAs on patients undergoing endoscopy. The outcomes of interest were odds of retained gastric content (RGC), aspiration risk, and aborted and repeated procedures. A random effect model was used to calculate the pooled odds of outcomes with a 95% CI. We further calculated the pooled odds of predictive factors associated with an increased rate of retained gastric residues in the study population. Results: We included 12 studies with a total of 105,515 patients, of which 32,144 were on GLP-1 RAs and 73,273 were in the control group. A total of 234 (0.73%) aspiration events in GLP-RA users were noted compared to 257 (0.35%) events in the control group. No increased odds (1.26, 95% CI 0.86-1.87, I2 34%) of aspiration were found in GLP-1 users compared to the non-GLP-1 group. Patients on GLP-1 RA had increased RGC compared to the control group (OR 6.30, 95% CI 5.30-7.49, I2 0%). The pooled odds of aborted (OR 5.50, 95% CI 3.25-9.32, I2 0%) and repeated procedures (OR 2.19, 95% CI 1.42-3.38, I2 0%) were significantly higher in GLP-1 RA users. Patients taking Tirazepatide had the highest percentage of RGC (18.9%), while exenatide users had the lowest rate (6.2%) of food retention. Patients undergoing concomitant colonoscopy were found to have significantly low pooled odds of RGC (OR 0.26, 95% CI 0.04-0.48). GLP-1 RAs use was independently associated with increased odds of RGC (3.91, 95% CI 3.21-4.62, I2 0%). The results were homogenous and stayed consistent in the sensitivity analysis. Conclusions: Although the odds of RGC and aborted procedures are high in the GLP-1 RAs group compared to the control, no significant difference in the odds of aspiration was found between the two groups. Simple measures such as a clear liquid diet for 24 h, as routinely set for patients undergoing colonoscopy, may reduce the risk of retaining gastric residue in these patient populations.

Postoperative Aspiration Pneumonia Among Adults Using GLP-1 Receptor Agonists

Importance

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have been increasingly prescribed for weight management in recent years. However, little is known about whether preoperative GLP-1 RA use is associated with a greater risk of complications after surgery.

Objective

To investigate whether preoperative GLP-1 RA use is associated with postoperative aspiration pneumonia among patients undergoing common surgical procedures.

Design, Setting, and Participants

This retrospective cohort study, conducted using MarketScan commercial claims databases, included patients who underwent 1 of 14 common surgical procedures from April 1, 2020, to September 30, 2022. Individuals who were younger than 18 years, underwent multiple surgical procedures, or had a preoperative history of pneumonia or acute respiratory failure in the 90 days preceding surgery were excluded. Data were analyzed from December 2023 to March 2024.

Main Outcome and Measures

The primary outcome was aspiration pneumonia in the 30-day postoperative period. Multivariable logistic regressions were performed, adjusting for patient and surgical characteristics.

Results

This study included 366 476 patients (median age, 53 years [IQR, 43-62 years]), of whom 56.4% were women. In the cohort, 5931 patients (1.6%) had a preoperative prescription for a GLP-1 RA. Patients using GLP-1 RAs were more likely to be female (3502 [59.0%] vs 203 288 [56.4%]) and diagnosed with both obesity and diabetes (2819 [47.5%] vs 24 635 [6.8%]) compared with nonusers. Adjusted analysis showed no significant differences in the odds of postoperative pneumonia (odds ratio, 0.78; 95% CI, 0.57-1.06; P = .12) between GLP-1 RA users and nonusers.

Conclusions and Relevance

This cohort study found no significant association between the preoperative use of GLP-1 RAs and short-term postoperative aspiration pneumonia despite growing concerns about the adverse effects of these medications after surgery. This finding suggests that it may be beneficial to reassess the preoperative withholding guidelines for GLP-1 RAs.

Perioperative glucagon-like peptide-1 receptor agonist use and retained gastric contents: A retrospective analysis of patients undergoing elective upper endoscopy

INTRODUCTION

Glucagon-like peptide-1 receptor (GLP-1R) agonists have been increasingly prescribed for weight loss and glycemic control. The potential side effect of slowed gastric emptying may increase risk of regurgitation and aspiration. Our primary aim was to investigate the incidence of retained gastric contents (RGCs) among appropriately fasted patients taking a GLP-1R agonist compared to those not taking a GLP-1R agonist presenting for upper gastrointestinal endoscopy (UE).

METHODS

A retrospective chart review of patients undergoing UE was conducted. For the GLP-1R group, included were patients aged 18 years or older who had documentation of taking a GLP-1R agonist within 30 days prior to the procedure, adhered to standard fasting guidelines, and had clear documentation in the electronic medical record of gastric findings during endoscopy. This group was compared to a group of agematched controls. The primary outcome was the incidence of RGCs. Secondary outcome included a propensity-weighted analysis of the odds ratio of taking a GLP-1R and having RGCs.

RESULTS

Included were 940 patients who presented for UE between July 2022 and December 2023 (470 GLP-1R and 470 controls). RGCs were found in 59/470 (12.6 %) of GLP-1R patients compared to 26/470 (5.5 %) of controls (P < 0.001). Propensity-weighted analysis found a significant association between the use of GLP-1R and retained gastric contents [OR = 1.92, 95 % CI (1.04, 3.53)].

CONCLUSIONS

A higher incidence of RGCs was found in appropriately fasted patients on a GLP-1R agonist who presented for UE. After controlling for the differences between the two study groups, RGC's were correlated to GLP-1R agonist use. Anesthesiologists should remain vigilant regarding a potential increased risk of RGCs in appropriately fasted patients taking a GLP-1R agonist who present for surgery.

What is the evidence regarding the safety of new obesity pharmacotherapies

The use of gut-hormone receptors agonists as new therapeutic options for obesity and some of its related comorbidities, such as type 2 diabetes, has resulted in an unprecedented efficacy in the medical management of people living with obesity (PLWO). Appraisal of the safety of these drugs is of utmost importance considering the large number of PLWO, and the potentially long exposure to these pharmacotherapies. In this narrative review we summarize the evidence on the safety of liraglutide, semaglutide, and tirzepatide as derived from randomized clinical trials conducted in adults living with obesity. Additionally, the safety of these drugs is put into perspective with that of other drugs currently approved for the treatment of PLWO. Overall, the available data support a favorable efficacy versus safety balance for gut-hormone hormone receptor analogues in the treatment of these subjects. Nonetheless, it should be acknowledged that in the context of a chronic disease that has reached epidemic proportions, data from randomized clinical trials aimed primarily at proving the efficacy of these drugs may have been insufficient to unveil all the safety issues. Thus, continuous surveillance on the adverse effects of liraglutide, semaglutide, and tirzepatide is required as we use these drugs in a broader population than that represented in currently available clinical trials.

Glucagon-Like Peptide Receptor Agonists Use Before Endoscopy Is Associated With Low Retained Gastric Contents: A Multicenter Cross-Sectional Analysis

INTRODUCTION

While ubiquity of glucagon-like peptide receptor agonists (GLP1-RAs) is rising, guidance from the gastroenterology societies and American Society of Anesthesiologist (ASA) remains in conflict on recommendations regarding preoperative holding before endoscopy. The aim of this study was to address this by evaluating the effect of GLP1-RAs on gastric retention during upper endoscopy.

METHODS

This multicenter cross-sectional study included patients on confirmed GLP1-RAs receiving an endoscopy from 2021 to 2023. Demographics, prescribing practices, and procedure outcomes were captured. GLP1-RA management of preoperative holding was retroactively classified per ASA guidance. Multivariable logistic regression was performed to assess factors influencing retained gastric contents.

RESULTS

Of 815 patients, 70 (8.7%) had retained gastric contents on endoscopy of whom 65 (93%) had type 2 diabetes mellitus. Only 1 (1.4%) of these patients required unplanned intubation, and none had aspiration events. Those with GLP1-RA held per ASA guidance (406, 49.8%) were less likely to have retained contents (4.4% vs 12.7%, P < 0.001), but there were no significant differences to intubation (0% vs 2%, P = 0.53) or aborting procedure rates (28% vs 18%, P = 0.40) due to gastric retention. On multivariable analysis, likelihood of food retention increased 36% (95% confidence interval 1.15-1.60) for every 1% increase in hemoglobin A1C after adjusting for GLP1-RA type and preoperative medication hold.

DISCUSSION

In this multicenter study, very low rates of retained gastric contents were seen during endoscopy in patients on GLP1-RAs and most were in patients with type 2 diabetes mellitus. Our findings suggest an individualized approach rather than universal preoperative holding of medications before endoscopy.

Low Rates of Aborted Endoscopy Due to Gastric Food Retention in Patients on Glucagon-Like-Peptide-1 Receptor Agonists

BACKGROUND

Glucagon-like peptide-1 receptor agonist (GLP-1 RA) use has dramatically increased with expanded indications for weight loss. Delayed gastric emptying due to these medications can lead to residual food in the stomach, which can increase the risk of periprocedural aspiration during endoscopic procedures. The aim of this study is to document rates of gastric food retention and aspiration events during upper endoscopy in patients on GLP-1 RA.

METHODS

A retrospective cohort study was performed including all patients who underwent upper endoscopic procedures at two hospitals during 2018-2023. Procedure abortion due to the presence of food was taken as primary study endpoint. The secondary endpoint was aspiration events in patients with food noted on endoscopy.

RESULTS

Out of a total of 32,275 total upper endoscopic procedures performed during the study period, 1179 procedures were performed in patients taking GLP-1 RAs (GLP-1 cohort). In total, 37 endoscopies (0.1%) were aborted due to retained gastric food; 7 patients (0.6%) in the GLP-1 cohort vs 30 patients (0.096%) in the non GLP-1 cohort (p < 0.01). There were no episodes of aspiration in patients with retained food.

CONCLUSIONS

In a large retrospective cohort, GLP-1 RA use did increase rates of gastric food retention during upper endoscopy, though the absolute risk was minimal. There were no aspiration events related to gastric food retention. Because of the small number of events, there were no clear modifiable risk factors for gastric food retention. This study supports the practice of individualized periprocedural management in patients on GLP-1 RA.

Point-of-care ultrasound training among anesthesiology residency programs in the United States

BACKGROUND

Point-of-care ultrasound (POCUS) use has become ubiquitous in the field of anesthesiology. However, POCUS training curriculum in anesthesiology residencies vary widely. We performed a survey study to better understand the structure of existing POCUS training and identify barriers to instituting a POCUS curriculum for anesthesiology trainees.

Screening and management of hospital hyperglycemia in non-critical patients: a position statement from the Brazilian Diabetes Society (SBD)

BACKGROUND

Hospital Hyperglycemia (HH) is linked to poorer outcomes, including higher mortality rates, increased ICU admissions, and extended hospital stays, and occurs in both people living with diabetes or not. The prevalence of HH in non-critical patients ranges from 22 to 46%. This panel reviewed the evidence and made recommendations for the best care for hospitalized hyperglycemic patients, with or without diabetes mellitus.

METHODS

The methodology was published previously and was defined by the internal institutional steering committee. The SBD Acute and Hospital Complications Department drafted the manuscript, selecting key clinical questions for a narrative review using MEDLINE via PubMed. The best available evidence was reviewed, including randomized clinical trials (RCTs), meta-analyses, and high-quality observational studies related to Hospital Hyperglycemia.

RESULTS AND CONCLUSIONS

The department members and external experts developed 23 recommendations for the management of patients with HH, including screening, initial interventions, treatment adjustments, and care for potential complications. Based on the best available evidence, our article provides safe and effective management strategies for both public and private healthcare settings.

Evaluation of gastric content in fasting patient during semaglutide use: an observational study

BACKGROUND

The evident influence of GLP-1 agonists as semaglutide on gastric emptying even in adherence to recommended fasting protocols instigates debates.

OBJECTIVE

To investigate the effect of semaglutide on gastric content by gastric ultrasonography in volunteers.

SETTING

Private hospital.

METHODS

The present study is an observational, cross-sectional, and single-center study. We included 30 consecutive volunteers aged ≥18 years who had undergone a minimum fasting period of 8 hours for solid foods and 2 hours for clear, residue-free liquids. The intervention group consisted of 15 volunteers who had used semaglutide within the last 7 days, whereas the control group consisted of 15 volunteers who had never used semaglutide. The main objective was to determine whether the stomach was full or not.

RESULTS

Between June 2023 and August 2023, a total of 30 adult volunteers were included in the study, and no participant was excluded. The semaglutide group exhibited a higher prevalence of full stomach (11 of 15 [73%] versus 1 of 15 [7%], P < .001; adjusted to age P = .003). The semaglutide group also exhibited a higher prevalence of early satiety (10 of 15 [67%] versus 0 of 15 [0%], P < .001), loss of appetite (10 of 15 [67%] versus 0 of 15 [0%], P < .001), gastric fullness (8 of 15 [53%] versus 0 of 15 [0%], P = .002), and nausea (7 of 15 [47%] versus 1 of 15 [7%], P = .035). Additionally, there is no case in the semaglutide group with no gastric contents.

CONCLUSIONS

The use of semaglutide is associated with full stomach even after appropriate overnight fasting. Semaglutide is also associated with increased gastrointestinal symptoms such as loss of appetite, early satiety, gastric fullness, and nausea.

A systematic review of the use of GLP-1 receptor agonists in surgery

BACKGROUND

Surgeons are likely to encounter patients on GLP-1 receptor agonists (GLP-1RAs) and should be aware of any associated risks or complications. Here we review the existing literature on GLP-1RA use as it pertains to non-bariatric surgeons.

METHODS

A systematic review was conducted following PRISMA 2020 guidelines. Three databases were queried for articles discussing the use of GLP-1RAs in a surgical context. Articles went through two rounds of manual screening.

RESULTS

21 articles were included in analysis, which found that pre-operatively, GLP-1RAs can aid patients in meeting the BMI threshold for surgery. Peri-operatively, GLP-1RAs were associated with improved glycemic control and lower intraoperative insulin use. Complications such as delayed gastric emptying and increased rates of hypoglycemic events were reported.

CONCLUSION

Surgeons may leverage GLP-1RAs to help prepare patients for surgery and should understand potential surgical complications associated with the use of these medications and to screen preoperative patients appropriately.

Assessment of residual gastric volume by ultrasound prior to upper endoscopy: a prospective cohort study

PURPOSE

Pulmonary aspiration is an adverse event with high morbidity and mortality. Despite fasting for > 8 hr, some patients still have residual gastric volume and are thus at risk of aspiration. We aimed to determine the accuracy of gastric ultrasound in assessing residual gastric content in patients undergoing upper gastrointestinal endoscopy.

METHODS

In a prospective cohort study, we performed gastric ultrasound immediately before upper gastrointestinal endoscopy in a sample of 294 patients. We categorized the ultrasound results as high risk of aspiration when the fluid volume was > 1.5 mL·kg-1 or when there was thick/solid content. We applied Spearman's test to determine the correlation between aspirated volume and ultrasound-estimated volume using three mathematical models. We assessed the method's accuracy by calculating its sensitivity and specificity.

RESULTS

We included 282 patients in the analysis. The incidence of residual gastric contents was 5%. There were no aspiration events. Prokinetic use (relative risk [RR], 7.5; 95% confidence interval [CI], 1.9 to 29.1; P < 0.01), previous stroke (RR, 4.0; 95% CI, 1.2 to 13.6; P = 0.02), and male sex (RR, 3.3; 95% CI, 1.2 to 9.4; P = 0.02) were significantly more frequent among those with residual gastric content. The ultrasonography's specificity and sensitivity to predict gastric content at risk of aspiration were 100% and 77%, respectively, with a positive predictive value of 100% and a negative predictive value of 99%.

CONCLUSION

Ultrasonography was an effective way to assess residual gastric content, which can help improve patient safety.

Glucagon-like peptide-1 receptor agonists and upper endoscopy: a real-world experience

OBJECTIVE

Increased use of glucagon-like peptide-1 receptor agonists (GLP-1RAs) has raised safety concerns during endoscopy due to their mechanism of delaying gastric emptying. This study aims to evaluate the impact of GLP-1RAs on technical success and safety of esophagogastroduodenoscopy (EGD).

METHODS

This was a retrospective study of bariatric patients who underwent EGD between January 2022 and December 2023. Only patients on GLP-1RAs were included and were categorized into those who held GLP-1RAs prior to EGD (GLP-HELD group) and those who did not (GLP-CONTINUED group). The primary outcome was technical success, defined as completion of EGD without interruption. Secondary outcomes included the presence of residual gastric contents during EGD and aspiration rates.

RESULTS

A total of 629 patients were included. Baseline age and BMI were mean (SD) 54.9 (13.0) years and 37.3 (8.0) kg/m2, respectively. Of 629 patients, 146 (23%) were in the GLP-HELD group, and 483 (77%) were in the GLP-CONTINUED group. For the primary outcome, rates of early termination of EGD were similar between groups (1.4% for GLP-CONTINUED vs. 0% for GLP-HELD; p = 0.36). For secondary outcomes, incidence of residual gastric contents was similar between groups (6.4% for GLP-CONTINUED vs. 2.7% for GLP-HELD; p = 0.09). There were no aspiration events in either group.

CONCLUSIONS

Continuation of GLP-1RAs did not appear to be associated with an increased incidence of residual gastric contents, early procedural termination, or aspiration events.

Glucagon-like peptide-1 receptor agonists significantly affect the quality of bowel preparation for colonoscopy

BACKGROUND

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) affect gastrointestinal motility, slowing gastric emptying and colonic transit. GLP-1RAs have an impact on gastric residue before endoscopy, but only limited data are available regarding its effect on the adequacy of colonic preparation. We investigated the association between GLP-1RA use and inadequate bowel preparation (IBP) for colonoscopy.

METHODS

We performed a multicenter retrospective study with GLP-1RA cases matched with controls (using propensity scores for age, sex, diabetes mellitus [DM], obesity, and co-morbidities). Data on demographics, medication use, procedural indications, and colonoscopy findings were collected. IBP ("poor preparation" on Aronchik scale or Boston Bowel preparation scale <5) was the primary outcome.

RESULTS

4876 patients treated with GLP-1RAs were included in the analysis and compared with 4876 controls selected from 333 648 patients without GLP-1RA use. Among the GLP-1RA patients, 10% (n = 487) had IBP compared with 197 (4%) of the control group (P<0.001). Subgroup analysis showed a higher rate of IBP among diabetic patients treated with GLP-1RA (284/2364 [12%]) than among diabetic patients without GLP-1RA treatment (118/2364 [5%]; P<0.001). Additionally, 203/2512 nondiabetic patients treated with GLP-1RAs had IBP (8%) compared with 79 of the nondiabetic non-GLP-1RA group (3%; P<0.001). On multivariate analysis, diabetes and GLP-1RA use were both found to be independent risk factors for IBP (odds ratio [OR] 1.4 and OR 2.7, respectively; both P<0.001).

CONCLUSION

Our findings highlight the necessity for special attention and tailored recommendations for both diabetic and nondiabetic patients treated with GLP-1RAs in terms of colonic preparation prior to colonoscopy.

Variability in the management of GLP-1 agonists and endoscopic procedures: an opportunity for standardization

Glucagon-like peptide-1 receptor agonists (GLP-1RAs), also known as incretin mimetics, have significantly revolutionized the treatment of type 2 diabetes mellitus (T2DM) and obesity worldwide, far exceeding initial expectations regarding their global prescription. This class of medications has demonstrated weight losses of up to 20 % of baseline body weight. Beyond their proven benefits in T2DM and obesity, GLP-1RAs, as well as dual and triple agonists (GLP-1/GIP/glucagon), are being investigated for their effects on conditions such as metabolic-associated steatotic liver disease, various cardiovascular disorders, neurocognitive impairments, and certain addictions. These emerging effects appear to be linked not only to their metabolic action but also to their ability to modulate the chronic inflammatory state underlying these pathologies.

Perioperative Use of GLP-1 Receptor Agonists in Patients Undergoing Cardiac Procedures: A Scoping Review

BACKGROUND

Glucagon-like peptide-1 receptor agonist (GLP-1RA) therapies are increasingly used for the treatment of type 2 diabetes mellitus and obesity. Despite growing awareness of potentially increased risk of pulmonary aspiration due to delayed gastric emptying, the risks and benefits of their perioperative use in patients undergoing cardiac procedures remains unexplored. A scoping review was performed to investigate the perioperative GLP-1RA use in patients undergoing cardiac procedures and recommendations.

METHOD

PubMed and Ovid MEDLINE were searched up to April 2024 to identify English-language studies on the perioperative use of weekly and daily dosed GLP-1RAs in adult patients undergoing cardiac procedures (including cardiac surgery, trans-oesophageal echocardiograms, and cardiac catheterisation procedures).

RESULTS

Three studies were identified, which investigated daily dosed GLP-1RAs in patients undergoing cardiac surgery. No studies were found investigating GLP-1RA use in cardiac catheterisation or trans-oesophageal echocardiograms procedures, and none which specifically examined risk of pulmonary aspiration in patients using GLP-1RAs undergoing cardiac procedures.

CONCLUSIONS

GLP-1RAs are beneficial for perioperative weight loss, glycaemic control, and cardiovascular health. Existing guidelines and consensus recommendations are highly contradictory on perioperative GLP-1RA management. Although no known published case reports exist to date of pulmonary aspiration in patients using GLP-1RAs undergoing cardiac procedures, non-cardiac surgical literature strongly suggests that patients are at theoretical risk and a cautious approach is advised in the absence of robust evidence informing recommendations for optimal withholding periods.

Glucagon-like peptide-1 receptor agonists in peri-operative care: Dispelling myths and unveiling insights with essential considerations for anaesthesiologists

With the growing use of glucagon-like-peptide-1 (GLP-1) receptor (GLP-1R) agonists as anti-obesity medication it is becoming increasingly important to examine its consequences in the peri-operative period. GLP-1R agonists are known for their effects of glucose-lowering and gastroparesis the latter causing some safety concerns regarding induction of anaesthesia, more specifically the risk of pulmonary aspiration. This article gathers the available evidence on this subject in addition to the already established guidelines. Current evidence makes us assume there is indeed an increased level of gastroparesis, but there are no studies to date with evidential confirmation of a presumed elevated risk of pulmonary aspiration. Future perspectives should focus on the actual risk of pulmonary aspiration and the possible implementation of ultrasound in the preoperative assessment.

Glucagon-like peptide-1 receptor agonists and capsule endoscopy in patients with diabetes: a matched cohort study

BACKGROUND AND AIMS

Video capsule endoscopy (VCE) is valuable for assessing conditions like GI bleeding, anemia, and inflammatory bowel disease. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are prescribed for diabetes and weight loss, with their pharmacologic effects including delayed gastric emptying. This study investigates the impact of GLP-1RA use on VCE outcomes in patients with diabetes.

METHODS

This retrospective cohort study involves patients with diabetes undergoing VCE while on GLP-1RAs matched in a 1:1 ratio with control subjects, who are not on GLP-1RAs, based on demographics and diabetes-related factors. The primary outcome was gastric transit time in VCE studies, whereas secondary outcomes were incomplete small-bowel evaluation and small-bowel transit time.

RESULTS

In the GLP-1RA cohort with 68 patients, 5 (7%) experienced failure to pass the video capsule through the stomach; all control subjects passed the video capsule successfully (P = .06). GLP-1RA patients had a longer gastric transit time (99.3 ± 134.2 minutes) compared with control subjects (25.3 ± 31.6 minutes, P < .001). Multivariate analysis revealed GLP-1RA use was associated with an increased gastric transit time by 74.5 minutes (95% confidence interval, 33.8-115.2; P < .001) compared with control subjects, after adjusting for relevant factors. Sixteen GLP-1RA patients (23.5%) experienced incomplete passage of the video capsule through the small intestine, a significantly higher rate compared with 3 patients in the control group (4.4%, P < .01).

CONCLUSIONS

GLP-1RA use is associated with a prolonged gastric transit time and a higher rate of incomplete small-bowel evaluation during VCE. Future studies may be crucial for evaluating strategies to mitigate these effects.

Effects of glucagon-like peptide-1 receptor agonists on endoscopy outcomes: systematic review and meta-analysis

BACKGROUND AND AIMS

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are known to cause delayed gastric emptying; however, the effect on clinical outcomes during upper endoscopy and colonoscopy remains unclear. We conducted a meta-analysis to reconcile the data.

METHODS

Online databases were searched for studies evaluating GLP-1RAs versus a control group (no GLP-1RAs) in patients undergoing endoscopy. The outcomes of interest were rate of retained gastric contents (RGCs), aborted procedures, aspiration events, and subjective bowel preparation quality. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using a random-effects model.

RESULTS

Twenty-three studies with 77,152 patients (4449 in the GLP-1RA arm and 72,703 in the control arm) were included. Mean patient age ranged from 47.6 to 72 years, and 58.4% were women. As compared with the control group, the GLP-1RA group had higher odds of RGCs (OR, 15.39; 95% CI, 4.65-50.99; P < .01) and aborted procedures (OR, 13.86; 95% CI, 4.42-43.43; P < .01). No significant differences were observed between the 2 groups in terms of aspiration events (OR, 21.06; 95% CI, .13-3379.01; P = .24) and subjective bowel preparation quality (OR, .94; 95% CI, .67-1.31; P = .83).

CONCLUSIONS

Although statistical significance was reached in terms of visible RGCs and early termination of endoscopies in patients on GLP-1RAs, these events were overall rare. GLP-1RAs do not appear to pose significant risk, as the odds of developing aspiration were comparable in the 2 groups.

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.

Considerations for Perioperative Management Guidance Regarding GLP-1 Receptor Agonists: Evaluation of Current Practices and Future Directions

INTRODUCTION

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have become increasingly prevalent and have the potential to delay gastric emptying. The American Society of Anesthesiologists (ASA) released guidance regarding the perioperative management of patients receiving GLP-1 RAs, but it is unclear the extent to which hospitals in the U.S. Military Health System have implemented policies consistent with this guidance.

METHODS

A questionnaire was sent to active duty anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs) working in the U.S. Military Health System. The questions assessed the presence of institutional GLP-1 RA perioperative policies, adherence to the policy (if applicable), the basis and components of current and recommended future institutional policies, institutional tracking of policy implementation and outcomes, and knowledge, skills, barriers, and continuing medical education goals related to the perioperative management of patients receiving GLP-1 RAs.

RESULTS

The response rate was 32% (N = 265); a little over half of the respondents were anesthesiologists (53%); and respondents' primary practices included over 50 institutions. More than half (54%) indicated that their primary practice location had a GLP-1 RA perioperative policy; 65% of whom indicated that they always followed the policy. In review of practice locations with >1 respondents, there was a lack of perfect agreement across most locations. The most commonly reported basis for the policy was ASA guidance (87%), followed by department leadership (37%). Barriers to any system-wide GLP-1 perioperative management policy included a lack of gastric ultrasound practice and comfort, as well as reported skills and knowledge, pressure not to cancel cases, scheduling problems, and productivity requirements.

CONCLUSIONS

Formal policies were reported by most respondents, but inconsistencies within practice locations suggest that local policy implementation could be improved. Commonly reported barriers to future system-wide policy implementation provide data-driven information for system-wide efforts to improve policy success.

Glucagon-Like Peptide-1 Receptor Agonists in the Peri-Operative Period

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are emerging as an important class of drugs in the management of Type 2 Diabetes Mellitus (T2DM) and obesity. There are rising concerns of pulmonary aspiration with these medications due to drug-induced gastroparesis. While definitive association is uncertain, it is essential to be prudent and manage these patients as per the current evidence and recommendations.

Point-of-Care Ultrasound in Gastroenterology and Hepatology

Point-of-care ultrasound (POCUS) is changing the practice of nearly all specialties and is increasingly being incorporated as a bedside tool by more gastroenterologists and hepatologists. POCUS is most often used to answer focused diagnostic questions, supplement the traditional physical examination, and guide performance of invasive bedside procedures. This review describes several common POCUS applications used in gastroenterology and hepatology, as well as some novel applications that warrant further investigation.

Glucagon-like Peptide-1 Receptor Agonists in the Management of Diabetic Retinopathy

Glucagon-like peptide-1 (GLP-1) receptor agonists are a family of drugs, most well known by the third-generation once-weekly subcutaneous semaglutide, that act on the incretin pathway of metabolic, hormonal signaling to modulate pancreatic insulin release, gastric emptying, energy intake, and subjective feelings of satiety. This class of drugs' efficacy and safety in the treatment of type 2 diabetes and obesity have been demonstrated across multiple large randomized controlled trials. These data have propelled GLP-1 receptor agonists to ubiquity in diabetic management and weight loss therapy, leading them to be frequently encountered in ophthalmic practice. The effect of GLP-1 receptor agonists like semaglutide on diabetic retinopathy (DR) is at this point unclear; some studies indicate a worsening of DR with the initiation of GLP-1 agonists, especially semaglutide. Overall, the macrovascular reduction of cardiovascular and stroke risks from GLP-1 receptor agonists should be prioritized over the potential microvascular progression of DR, as long as the patient is regularly followed by ophthalmology.

Preoperative assessment of adults undergoing elective noncardiac surgery: Updated guidelines from the European Society of Anaesthesiology and Intensive Care

BACKGROUND

When considering whether a patient is fit for surgery, a comprehensive patient assessment represents the first step for an anaesthetist to evaluate the risks associated with the procedure and the patient's underlying diseases, and to optimise (whenever possible) the perioperative surgical journey. These guidelines from the European Society of Anaesthesiology and Intensive Care Medicine (ESAIC) update previous guidelines to provide new evidence on existing and emerging topics that consider the different aspects of the patient's surgical path.

DESIGN

A comprehensive literature review focused on organisation, clinical facets, optimisation and planning. The methodological quality of the studies included was evaluated using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology. A Delphi process agreed on the wording of recommendations, and clinical practice statements (CPS) supported by minimal evidence. A draft version of the guidelines was published on the ESAIC website for 4 weeks, and the link was distributed to all ESAIC members, both individual and national, encompassing most European national anaesthesia societies. Feedback was gathered and incorporated into the guidelines accordingly. Following the finalisation of the draft, the Guidelines Committee and ESAIC Board officially approved the guidelines.

RESULTS

In the first phase of the guidelines update, 17 668 titles were initially identified. After removing duplicates and restricting the search period from 1 January 2018 to 3 May 2023, the number of titles was reduced to 16 774, which were then screened, yielding 414 abstracts. Among these, 267 relevant abstracts were identified from which 204 appropriate titles were selected for a comprehensive GRADE analysis. Additionally, the study considered 4 reviews, 16 meta-analyses, 9 previously published guidelines, 58 prospective cohort studies and 83 retrospective studies. The guideline provides 55 evidence-based recommendations that were voted on by a Delphi process, reaching a solid consensus (>90% agreement).

DISCUSSION

This update of the previous guidelines has covered new organisational and clinical aspects of the preoperative anaesthesia assessment to provide a more objective evaluation of patients with a high risk of postoperative complications requiring intensive care. Telemedicine and more predictive preoperative scores and biomarkers should guide the anaesthetist in selecting the appropriate preoperative blood tests, x-rays, and so forth for each patient, allowing the anaesthetist to assess the risks and suggest the most appropriate anaesthetic plan.

CONCLUSION

Each patient should have a tailored assessment of their fitness to undergo procedures requiring the involvement of an anaesthetist. The anaesthetist's role is essential in this phase to obtain a broad vision of the patient's clinical conditions, to coordinate care and to help the patient reach an informed decision.

Medical Weight Management Considerations in Plastic Surgery

SUMMARY

Obesity is one of the greatest public health concerns in the United States and has reached an epidemic scope over the past few decades. Plastic surgery in patients with obesity has been linked to higher complication rates both before and after weight loss. This article discusses the evolution and landscape of antiobesity medications as they apply to plastic surgery. Although bariatric surgery has been effective in long-term treatment, new pharmacologic advances in glucagon-like peptide-1 agonists, such as semaglutide, have demonstrated promising effectiveness. These medications pose several unique challenges, particularly with regard to perioperative management and risk of weight regain after discontinuation. An understanding of these new pharmacologic agents is crucial for plastic surgeons, who treat patients with obesity.

Glucose-Lowering Agents Developed in the Last Two Decades and Their Perioperative Implications

The last two decades have provided far more options f both patients and their physicians in the treatment of diabetes mellitus. While dipeptidyl peptidase-4 inhibitors (DPP-4is) and glucagon-like peptide 1 receptor agonists (GLP-1RAs) have been approved for nearly two decades, sodium-glucose cotransporter 2 inhibitors (SGLT-2is) are relatively new. Of interest to perioperative physicians, these drugs present specific perioperative concerns, prompting many societies to issue guidelines. Retained gastric contents due to slow gastric emptying is a significant drawback of GLP-1RAs, increasing the risk of aspiration. Recommendations include withholding GLP-1RAs for a predefined period of time, performing gastric ultrasound to evaluate gastric contents, modifying anesthesia management, particularly with regard to the airway, or canceling the scheduled (elective) surgery or procedure. SGLT-2is are known to increase the risk of euglycemic ketoacidosis. The benefits of both GLP-1RAs and SGLT-2is extend beyond the treatment of diabetes. As a result, perioperative physicians may encounter their use outside of their traditional indications. SGLT-2is are being used extensively to treat heart failure and obesity, for example. There have been other developments as well. For instance, Imeglimin, a variant of metformin available in Japan and India, Icodec, a once-weekly basal insulin formulation, and IcoSema, a once-weekly combination of Icodec plus semaglutide, are all being explored, although in their early stages or facing approval challenges.

Clinical Consequences of Delayed Gastric Emptying With GLP-1 Receptor Agonists and Tirzepatide

CONTEXT

Glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) are established therapeutics for type 2 diabetes and obesity. Among other mechanisms, they slow gastric emptying and motility of the small intestine. This helps to limit postprandial glycemic excursions and reduce chylomicron formation and triglyceride absorption. Conversely, motility effects may have detrimental consequences, eg, retained gastric contents at endoscopy or general anesthesia, potentially complicated by pulmonary aspiration or bowel obstruction.

DATA ACQUISITION

We searched the PubMed database for studies involving GLP-1RA therapy and adverse gastrointestinal/biliary events.

DATA SYNTHESIS

Retained gastric contents at the time of upper gastrointestinal endoscopy are found more frequently with GLP-1 RAs but rarely are associated with pulmonary aspiration. Well-justified recommendations for the periprocedural management of GLP-1RAs (eg, whether to withhold these medications and for how long) are compromised by limited evidence. Important aspects to be considered are (1) their long half-lives, (2) the capacity of GLP-1 receptor agonism to slow gastric emptying even at physiological GLP-1 concentrations, (c) tachyphylaxis observed with prolonged treatment, and (d) the limited effect on gastric emptying in individuals with slow gastric emptying before initiating treatment. Little information is available on the influence of diabetes mellitus itself (ie, in the absence of GLP-1 RA treatment) on retained gastric contents and pulmonary aspiration.

CONCLUSION

Prolonged fasting periods regarding solid meal components, point-of-care ultrasound examination for retained gastric content, and the use of prokinetic medications like erythromycin may prove helpful and represent an important area needing further study to increase patient safety for those treated with GLP-1 RAs.

Perioperative Considerations for Patients on GLP1 Agonists

GlP-1 receptor agonists are a class of medications that are becoming increasingly popular. Large trials have shown that their use provides reliable weight loss in obese patients and improved glycemic control in diabetic patients. Its use also has broader implications for overall metabolic health and has been shown to improve cardiovascular outcomes in high-risk populations. Glucagon-like peptide 1 receptors cause multiple effects in the body through stimulation of receptors expressed in a broad range of tissues including the pancreas, liver, gastrointestinal tract, kidneys, heart, endothelium, muscle, and brain. For the anesthesia professionals the effects of these medications on gastric emptying is important.