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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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Oleru OO, Mandelbaum MG, Seyidova N, Taub PJ. Surgical Implications of GLP-1 Agonists for Weight Loss: Are These Patients Suitable for Elective Surgery? Plast Reconstr Surg 2024; 154:411e-412e. [PMID: 38262614 PMCID: PMC11263498 DOI: 10.1097/prs.0000000000011313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Affiliation(s)
- Olachi O Oleru
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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do Nascimento TS, Pereira ROL, Maia E, Ohnuma T, da Costa MG, Slawka E, Galhardo C, Krishnamoorthy V. The impact of glucagon-like peptide-1 receptor agonists in the patients undergoing anesthesia or sedation: systematic review and meta-analysis. Perioper Med (Lond) 2024; 13:78. [PMID: 39039540 PMCID: PMC11264430 DOI: 10.1186/s13741-024-00439-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 07/16/2024] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND Glucagon-like peptide-1 agonist receptors (GLP-1RAs), medications used for glycemic control and weight loss, are increasing worldwide. In the perioperative period, the major concern related to GLP-1RA is gastric emptying delay and risk of aspiration. This meta-analysis and systematic review compared the risks and benefits of using GLP-1 agonist receptors and control in surgical and nonsurgical procedures under anesthesia or sedation. METHODS We systematically searched MEDLINE, Embase, and Cochrane for randomized controlled trials and observational studies involving patients > 18 years undergoing elective surgeries or procedures. Outcomes of interest were pre-procedural gastrointestinal (GI) symptoms, residual gastric content assessed by endoscopy, pulmonary aspiration during anesthesia/sedation, perioperative glycemic control, postoperative inotropic support, nausea/vomiting (PONV), atrial fibrillation, and 30-day mortality rate. We used a random effects model, with odds ratio and mean difference computed for binary and continuous outcomes, respectively. RESULTS Fourteen randomized and observational studies with 2143 adult patients undergoing elective surgeries and procedures were included. GLP-1RA resulted in increased pre-procedural GI symptoms (OR 7.66; 95% CI 3.42, 17.17; p < 0.00001; I2 = 0%) and elevated residual gastric content (OR 6.08; 95% CI 2.86, 12.94; p < 0.00001; I2 = 0%). GLP-1RA resulted in lower glycemic levels (MD - 0.73; 95% CI - 1.13, - 0.33; p = 0.0003; I2 = 90%) and lower rate of rescue insulin administration (OR 0.39; 95% CI 0.23, 0.68 p = 0.0009; I2 = 35%). There was no significant difference in rate of perioperative hypoglycemia (OR 0.60; 95% CI 0.29, 1.24; p = 0.17; I2 = 0%), hyperglycemia (OR 0.89; 95% CI 0.59, 1.34; p = 0.58; I2 = 38%), need for postoperative inotropic support (OR 0.57; 95% CI 0.33, 1.01; p = 0.05; I2 = 0%), atrial fibrillation (OR 1.02; 95% CI 0.52, 2.01; p = 0.95; I2 = 16%), rate of PONV (OR 1.35; 95% CI 0.82, 2.21; p = 0.24; I2 = 0%), and 30-day mortality rate (OR 0.54; 95% CI 0.14, 2.05; p = 0.25; I2 = 0%). CONCLUSION Compared to control, pre-procedural GLP-1RA increased the rate of GI symptoms and the risk of elevated residual gastric content despite adherence to fasting guidelines. GLP-1RA improved glycemic control and decreased the rate of rescue insulin administration. There was no significant difference in the rates of perioperative hypo or hyperglycemia, postoperative inotropic support, PONV, atrial fibrillation, and 30-day mortality.
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Affiliation(s)
- Tatiana S do Nascimento
- Department of Anesthesiology, Cardoso Fontes Federal Hospital, Av. Menezes Cortes, Rio de Janeiro, RJ, 3245, Brazil.
| | - Rodrigo O L Pereira
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Eduardo Maia
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Tetsu Ohnuma
- Division of Critical Care, Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Mariana G da Costa
- Department of Anesthesiology, University Medical Center of Groningen, Groningen, The Netherlands
| | - Eric Slawka
- School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Carlos Galhardo
- Department of Anesthesiology, McMaster University & DeGroot School of Medicine, Hamilton, ON, Canada
| | - Vijay Krishnamoorthy
- Division of Critical Care, Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
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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. [PMID: 39086638 PMCID: PMC11287410 DOI: 10.3748/wjg.v30.i26.3221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [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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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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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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Parkman HP, Rim DS, Anolik JR, Dadparvar S, Maurer AH. Glucagonlike Peptide-1 Receptor Agonists: The Good, the Bad, and the Ugly-Benefits for Glucose Control and Weight Loss with Side Effects of Delaying Gastric Emptying. J Nucl Med Technol 2024; 52:3-7. [PMID: 38443105 DOI: 10.2967/jnmt.123.266800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/14/2023] [Indexed: 03/07/2024] Open
Abstract
Glucagonlike peptide-1 (GLP-1) receptor agonists (RAs) are being increasingly used for glycemic control in patients with diabetes and for weight loss and weight management in obese subjects. There has been recent public awareness of the potential of GLP-1 RAs to delay gastric emptying and cause gastroparesis. By delaying gastric emptying, these agents can complicate the clinical evaluation of patients on these drugs by affecting diagnostic testing for gastroparesis. This article discusses GLP-1 RAs and their effects on gastric emptying, gastric food retention, and gastroparesis. This article highlights how physicians should be attuned to the gastric side effects of these popular therapeutic agents for blood glucose control in people with diabetes and for weight loss and weight management in obese patients.
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Affiliation(s)
- Henry P Parkman
- Gastroenterology Section, Endocrinology and Metabolism Section, and Nuclear Medicine Section, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Daniel S Rim
- Gastroenterology Section, Endocrinology and Metabolism Section, and Nuclear Medicine Section, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Jonathan R Anolik
- Gastroenterology Section, Endocrinology and Metabolism Section, and Nuclear Medicine Section, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Simin Dadparvar
- Gastroenterology Section, Endocrinology and Metabolism Section, and Nuclear Medicine Section, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Alan H Maurer
- Gastroenterology Section, Endocrinology and Metabolism Section, and Nuclear Medicine Section, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
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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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