🎙️ Episode 43: GLP-1s Under the Knife – A Gut Check on Surgery Risks

Brilliant Board Review & CME

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🧠 Clinical Context

GLP-1 receptor agonists have taken center stage for both type 2 diabetes and obesity management, but their gastric side effects are giving anesthesiologists pause. The ASA's recent guidance recommends holding these agents before surgery to reduce risks of gastroparesis, regurgitation, and pulmonary aspiration.

🔬 ASA Guidelines Overview

• Daily Dosing? Hold on the day of surgery
• Weekly Dosing? Hold one week prior
• If asymptomatic and held as above? Proceed as usual

⚠️ But Here’s the Controversy

• There’s no strong evidence that holding GLP-1s as recommended reliably reduces gastric content risk.
• Recent endoscopy studies show no correlation between hold duration and gastric content retention.
• Gastroparesis risk may persist despite withholding the drug, especially in patients with:
  • Diabetes
  • Obesity
  • Opioid use
  • Alcohol, marijuana, or TCA use

🧪 What We Do Know

• Peak delay in gastric emptying appears within the first 12 weeks of therapy.
• Normalization of gastric motility might require holding meds for 5+ half-lives—often impractical.
• Meanwhile, GLP-1s improve glycemic control and may reduce post-op MACE (Major Adverse Cardiac Events).

🧭 Pragmatic Recommendations

• All GLP-1 patients should be considered at elevated aspiration risk, regardless of symptom status or hold duration.
• Use pre-op gastric ultrasound to assess contents.
• Plan anesthesia accordingly:
  • Airway protection
  • Rapid sequence induction
  • Appropriate surgical location

🍽️ Fasting Guidelines? A Gray Area

ASA’s updated fasting guideline (2023) applies to healthy patients without reflux, obesity, diabetes, or delayed emptying—aka, not your typical GLP-1 patient.

Recommendation: Modify fasting guidelines based on judgment. Don’t follow enhanced recovery protocols blindly.

🧩 Clinical Takeaway

Don’t assume that simply holding a GLP-1 agonist clears the gut. Evidence is lacking. Every GLP-1 patient should be approached with caution:

• Assume delayed gastric emptying
• Use tools like ultrasound for verification
• Customize fasting and airway protocols

🔍 Until we have more data, err on the side of protecting your patient’s airway—not just the guideline.

Key Reference: Ushakumari DS, Sladen RN. ASA Consensus-based Guidance. Anesthesiology. 2024 Feb;140(2):346–348. PMID: 37982170

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