New Guidance on GLP-1 Drugs for Surgery: What African Patients Need to Know

This article discusses the latest guidance from the American Society of Anesthesiologists (ASA) on using GLP-1 drugs, commonly prescribed for diabetes and weight loss, before elective surgery. Patients in Africa on GLP-1 medications like Ozempic and Saxenda no longer need to stop their regimen before elective procedures, except during new prescriptions or dose adjustments. The FDA's recent warning highlights a risk of pulmonary aspiration, making it essential for African patients to consult with their doctors before surgery. This guidance balances blood sugar management and surgical safety, with practical advice on pre-surgery precautions.

Nov 13, 2024 - 19:59
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New Guidance on GLP-1 Drugs for Surgery: What African Patients Need to Know

In a groundbreaking update, the American Society of Anesthesiologists (ASA) has recently released new guidance regarding the use of glucagon-like peptide-1 (GLP-1) receptor agonists for patients preparing for elective surgery. This updated guidance holds substantial implications for individuals in Africa and worldwide who are prescribed these drugs primarily for diabetes management and weight loss. The recommendation, published in association with multiple medical societies, suggests that most individuals using GLP-1 medications, such as liraglutide (Saxenda, Victoza), semaglutide (Ozempic, Rybelsus, Wegovy), and tirzepatide (Mounjaro, Zepbound), do not need to cease their medication before elective procedures. However, specific precautions and a clear communication pathway with healthcare providers remain essential, particularly due to the recent warning from the United States Food and Drug Administration (FDA) about risks associated with pulmonary aspiration.

Overview of the ASA Guidance on GLP-1 Drugs in Surgical Patients

The American Society of Anesthesiologists' (ASA) new recommendation introduces a refined protocol for patients prescribed GLP-1 receptor agonists who are scheduled for elective surgeries or procedures that require general anesthesia or deep sedation. According to the guidance, most individuals taking GLP-1 drugs for conditions such as diabetes or weight management can continue their regimen, provided their dose remains stable. However, the ASA advises against starting or adjusting GLP-1 dosages immediately before surgical procedures, a recommendation made in light of the unique pharmacological effects of these drugs on the gastrointestinal system.

GLP-1 receptor agonists function by slowing gastric emptying, thereby regulating glucose levels and aiding in weight reduction (American Society of Anesthesiologists, 2024). This delayed stomach emptying can potentially increase the risk of pulmonary aspiration—an occurrence where stomach contents are regurgitated and accidentally inhaled into the lungs. Pulmonary aspiration can lead to aspiration pneumonia, a severe, potentially life-threatening condition, which poses heightened risk under anesthesia.

FDA’s Warning on Pulmonary Aspiration and GLP-1 Medications

Recently, the FDA added a cautionary label to GLP-1 drugs to underscore the risk of pulmonary aspiration in patients under general anesthesia or deep sedation (FDA, 2024). This regulatory update aligns with the ASA's concerns raised over a year ago regarding aspiration risks associated with the slowed digestion induced by GLP-1s. Dr. Girish P. Joshi, MBBS, MD, vice chair of the ASA’s Committee on Practice Parameters, emphasized that the FDA’s warning corroborates the ASA's recommendations. He stated, “The ASA’s updated guidance provides an approach to mitigate this complication, but it does not downplay the potential for pulmonary aspiration” (Joshi, 2024).

The new FDA warning advises patients taking GLP-1 receptor agonists to inform their healthcare provider before any surgical procedure, particularly those involving deep sedation. The risk associated with residual gastric contents is of particular concern during these surgeries. The ASA encourages patients and clinicians to recognize the importance of this caution, particularly as the popularity of GLP-1 drugs increases due to their efficacy in managing chronic conditions like diabetes and obesity.

Balancing Risk and Benefit: A Multidisciplinary Approach

The recent guidance has been endorsed by various professional medical associations, including those representing gastroenterologists and bariatric surgeons. This collaborative support highlights the importance of an integrated approach to patient care, balancing the benefits of continued GLP-1 use against the risks of pulmonary aspiration. For patients with diabetes, maintaining stable blood glucose control is critical, even during the perioperative period (Surgery for Obesity and Related Diseases, 2024).

To mitigate aspiration risks, some patients may require individualized preparations before surgery. These preparations include following a liquid diet for up to 24 hours before the procedure or undergoing an ultrasound to assess gastric contents. In certain cases, a postponement of the procedure might be warranted to ensure patient safety. For patients experiencing gastrointestinal side effects, such as nausea, discomfort, or constipation—a common side effect during GLP-1 dose titration—a delay of four to eight weeks may be recommended. Additionally, individuals with underlying conditions that further slow stomach emptying, such as Parkinson’s disease, should engage in detailed preoperative discussions with their healthcare team to determine the best course of action.

Dr. Joshi noted that while delaying elective procedures is generally unnecessary, emergency surgeries may require specialized protocols to minimize aspiration risks. This approach ensures that patient care remains flexible and adaptive to the unique challenges presented by GLP-1 drugs without compromising safety.

Detailed Label Warning and Case Studies: A Cautious Perspective

The updated label on GLP-1 medications clearly states that post-marketing reports have identified rare cases of pulmonary aspiration in patients adhering to preoperative fasting guidelines, yet still experiencing residual gastric contents. Although the FDA's statement does not specify the frequency or outcomes of such cases, it stresses the necessity for caution and vigilance among healthcare professionals.

In an African context, where diabetes and obesity rates are on the rise, these guidelines are essential in ensuring safe surgical outcomes for patients. Acknowledging the growing reliance on GLP-1 receptor agonists, healthcare providers are urged to take the necessary precautions and communicate effectively with their patients about the potential risks and required preparations.

Conclusion

In summary, the ASA’s updated guidance provides an evidence-based approach for managing the perioperative care of patients taking GLP-1 receptor agonists. By continuing GLP-1 medications before elective surgeries, healthcare providers can uphold the benefits of optimal blood glucose control while minimizing risks through tailored perioperative practices. The endorsement from various medical societies further solidifies the approach as a balanced, multidisciplinary strategy aimed at ensuring patient safety and effective diabetes and weight management.

As GLP-1 receptor agonists become increasingly prevalent across Africa, particularly in the management of chronic conditions like diabetes, it is vital for patients to maintain open communication with their healthcare providers about any upcoming procedures. The new guidance emphasizes that although risks are rare, individualized care remains paramount. This update reinforces the ASA’s role in promoting patient safety and adapting to the evolving landscape of diabetes and obesity management.

References

American Society of Anesthesiologists. (2024). Most patients can continue diabetes, weight loss GLP-1 drugs before surgery, those at highest risk for GI problems should follow liquid diet before procedure.

FDA. (2024). Drug Safety-related Labeling Changes (SrLC) Database.

Joshi, G. P., MBBS, MD. (2024). Vice chair, Committee on Practice Parameters, American Society of Anesthesiologists; professor of anesthesiology and pain management, University of Texas Southwestern Medical Center, Dallas.

Surgery for Obesity and Related Diseases. (2024). Multisociety clinical practice guidance for the safe use of glucagon-like peptide-1 receptor agonists in the perioperative period.

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