No X-Ray Proof of Rare Surgical Complication Tied to GLP-1 Agonists

PHILADELPHIA — Chest x-rays did not support the existence of an aspiration risk for surgical candidates using GLP-1 receptor agonists, according to a retrospective study.

During the years when patients got the same anesthetic management regardless of whether they were on a GLP-1 receptor agonist or not, x-rays indicated some excess in potential aspiration events among users (4.158% vs 0.264%, P

However, the number of verified aspiration events came out to just 20 events, all identified from anesthesia notes and all in GLP-1 agonist nonusers. None could be detected from the chest x-rays alone, according to their report here at the American Society of Anesthesiologists (ASA) annual meeting.

“Our crude results indicate limited association between GLP-1 agonist usage and aspiration events. As described in other studies, we highlight the difficulty of detecting extremely rare surgical complications,” Guymon told the audience at ASA.

GLP-1 receptor agonists are known to have potential gastrointestinal side effects such as diarrhea and constipation due to delayed gastric emptying. Anecdotal reports suggested that the delay in stomach emptying could result in regurgitation and aspiration of food into the airways and lungs during general anesthesia and deep sedation.

Due to these concerns, ASA issued a statement last year expressing concerns about anesthesia for patients using GLP-1 receptor agonists. Patients on these medications were generally urged to hold the most recent dose prior to elective surgery. This usually meant a blanket hold on the medications for about a week.

Since those guidelines were released, a debate has arisen regarding how long of a wait is actually necessary — some groups reportedly intubating every surgical patient who is taking one of the weight-loss drugs. Recently, some data even question the validity of the aspiration concerns.

“The jury’s out,” said session co-moderator Andrew Feit, MD, of Stony Brook Medicine in Woodbury, New York.

Feit encouraged the use of gastric ultrasound to assess stomach contents the day of surgery, as some patients do not comply with presurgical tests. Most patients, he said, turn out to be empty enough with “maybe just some liquid” that it’s deemed OK to proceed with the operation, sometimes with rapid sequence intubation as a precaution in some cases.

Guymon stressed an individualized approach for each patient and said his institution has extended the hold on GLP-1 agonists out to 2 weeks for longer-acting GLP agonists. The concern with that, he acknowledged, is the question of glucose control for people with diabetes.

Feit’s co-moderator Maria Michaelis, MD, of University of Nebraska Medical Center in Omaha, said her institution has kept the rule of holding off GLP agonists for 1 week but predicted that more guidance will arrive in the future.

The GLP-1 receptor agonists were first developed as a treatment for type 2 diabetes and have since become popular as weight-loss drugs. Some of the most commonly prescribed agents belonging to this class include semaglutide (Ozempic, Rybelsus, Wegovy), liraglutide (Victoza, Saxenda), dulaglutide (Trulicity), and tirzepatide (Mounjaro, Zepbound).

“There is a stigma associated with the GLP-1 agonists … just something to be considerate of from a sensitivity standpoint,” cautioned Garret Weber, MD, of Westchester Medical Center in Valhalla, New York, another session co-moderator. Weber encouraged the audience to “recognize that patients may not always mention it during preoperative management.” He said he recalled a handful of patients who admitted being on the medications only the day of the surgery because they didn’t want to mention it earlier in front of family.

Guymon and colleagues limited their retrospective study to the period from January 2018 to May 2023, before the ASA guidelines came out. Included were all patients with type 2 diabetes or obesity undergoing surgery or an endoscopic procedure at Monument Health in Rapid City, split into controls not on a GLP-1 receptor agonist (n=23,484) and those on one (n=3,319).

Researchers sought to analyze postoperative chest x-rays that had been ordered immediately, within 1 day post-surgery, for any concern of serious aspiration during anesthesia. This approach to identifying such a rare complication, Guymon said, was like looking for a needle in a haystack.

Perhaps the team would have been better served if the pool of chest x-rays had been expanded out to the 48-72 hour period, he suggested.

In any case, the present analysis was still limited by the lack of accounting for variables such as the different types and doses of GLP-1 agonists used, the difference between a surgery versus endoscopic approach, or type of airway selected for surgery.

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