GLP1 meds and fasting

[jope]

Looks like the ASA has issued an update about guidelines for this drug.

Day or week prior to the procedure:

• Hold GLP-1 agonists on the day of the procedure/surgery for patients who take the medication daily.
• Hold GLP-1 agonists a week prior to the procedure/surgery for patients who take the medication weekly.
• Consider consulting with an endocrinologist for guidance in patients who are taking GLP-1 agonists for diabetes management to help control their condition and prevent hyperglycemia (high blood sugar).

Day of the procedure:

• Consider delaying the procedure if the patient is experiencing GI symptoms such as severe nausea/vomiting/retching, abdominal bloating or abdominal pain and discuss the concerns of potential risk of regurgitation and aspiration with the proceduralist or surgeon and the patient.
• Continue with the procedure if the patient has no GI symptoms and the GLP-1 agonist medications have been held as advised.
• If the patient has no GI symptoms, but the GLP-1 agonist medications were not held, use precautions based on the assumption the patient has a “full stomach” or consider using ultrasound to evaluate the stomach contents. If the stomach is empty, proceed as usual. If the stomach is full or if the gastric ultrasound is inconclusive or not possible, consider delaying the procedure or proceed using full stomach precautions. Discuss the potential risk of regurgitation and aspiration of gastric contents with the proceduralist or surgeon and the patient.

Patients Taking Popular Medications for Diabetes and Weight Loss Should Stop Before Elective Surgery, ASA Suggests

With the growing popularity of medications like Ozempic® (semaglutide), Trulicity® (dulaglutide), and other glucagon-like peptide-1 (GLP-1) receptor agonists for the treatment of type 2 diabetes and weight loss, the American Society of Anesthesiologists (ASA) suggests withholding the medication...

www.asahq.org

---

Members don't see this ad.

 

[Ezekiel2517]

I think we’ll be seeing it more and more. “In patients with heart failure with preserved ejection fraction and obesity, semaglutide (2.4 mg) led to greater reductions in symptoms and physical limitations and greater improvements in exercise function than placebo. Full STEP-HFpEF trial:”

https://www.nejm.org/doi/full/10.1056/NEJMoa2306963

 

[BLADEMDA]

Will the use of preop Gastric Ultrasound become routine on patients taking Semaglutide or Tirzepartide?

_________________________

It may be prudent to re-evaluate traditional fasting guidelines in these patients. A more systematic approach to assessing risk in this patient population may be necessary. The use of gastric ultrasound to define gastric contents prior to anesthesia can be considered in patients presenting for anesthesia on these medications, when available.19-21 If ultrasound is not available, there currently are no recommendations regarding optimal management. In the setting of uncertainty regarding gastric contents, rapid sequence induction of anesthesia and gastric decompression prior to emergence could be considered. It should also be recognized that risk for emesis and aspiration during emergence is also a real concern even with gastric decompression if the patient has residual solid gastric contents.

Are Serious Anesthesia Risks of Semaglutide and Other GLP-1 Agonists Under-Recognized? Case Reports of Retained Solid Gastric Contents in Patients Undergoing Anesthesia

Glucagon-like peptide (GLP-1) receptor agonists are an emerging and increasingly popular class of medications used for the treatment of type 2 diabetes mellitus and, more recently, obesity. Since the expansion of approved uses to include...

www.apsf.org

 

[nimbus]

Anybody else seeing their bariatric surgery volume decline? Ours is down 40-50%.

 

[dabears505]

Will these drugs end up being the cure for all diseases?

 

[chessknt]

Anybody else seeing their bariatric surgery volume decline? Ours is down 40-50%.

I cannot fathom why someone would opt fot bariatric surgery over the glp agonist route. Far less risk for similar if not superior efficacy in short term data.

 

[Dr. Rude]

I cannot fathom why someone would opt fot bariatric surgery over the glp agonist route. Far less risk for similar if not superior efficacy in short term data.

Cost. Bariatric surgery is more likely to be covered by insurance. These drugs are expensive and need to be taken for life.

 

[BLADEMDA]

 

[BLADEMDA]

Particulate Gastric Contents in Patients Prescribed Glucagon-Like Peptide 1 Receptor Agonists After Appropriate Perioperative Fasting: A Report of 2 Cases​

Wilson, Phillip Ryan MD; Bridges, Kathryn H. MD; Wilson, Sylvia H. MD

A & A Practice August 2023

In conclusion, the risk of perioperative aspiration with patients on GLP-1 therapy is not clear. However, as both our patients had large volumes of particulate gastric contents, a cautious approach is needed. Unfortunately, few studies currently exist specifically characterizing this issue, and larger, prospective studies involving endoscopic or ultrasonographic imaging to better assess anesthetic aspiration risk in these patients are needed.

 

[HalO'Thane]

View attachment 376274

What are we looking at? Pictures A and B look like we have a distended gastric antrum with thick liquid/solid. Picture C looks pretty small and collapsed with a classic "bulls eye" pattern consistent with an empty stomach.

 

[BLADEMDA]

Gastric Ultrasound

 

[BLADEMDA]

What are we looking at? Pictures A and B look like we have a distended gastric antrum with thick liquid/solid. Picture C looks pretty small and collapsed with a classic "bulls eye" pattern consistent with an empty stomach.

Figure.​

A, Sonographic findings consistent with a “full stomach” at baseline. The antrum (evaluated in the right lateral decubitus position) contains thick fluid/solid content. B, Sonographic findings consistent with a “full” stomach 60 min after administration of domperidone. C, Sonographic findings consistent with an “empty stomach” 90 min after presentation after the administration of domperidone and erythromycin. The antrum (evaluated in the right lateral decubitus position) appears completely empty (bull’s eye pattern) with no fluid or solid content. Ao indicates aorta; L, liver; P, pancreas; Sp, spine; yellow arrows, antrum.

 

[BLADEMDA]

View attachment 376274

​

​

​

Figure.​

A, Sonographic findings consistent with a “full stomach” at baseline. The antrum (evaluated in the right lateral decubitus position) contains thick fluid/solid content. B, Sonographic findings consistent with a “full” stomach 60 min after administration of domperidone. C, Sonographic findings consistent with an “empty stomach” 90 min after presentation after the administration of domperidone and erythromycin. The antrum (evaluated in the right lateral decubitus position) appears completely empty (bull’s eye pattern) with no fluid or solid content. Ao indicates aorta; L, liver; P, pancreas; Sp, spine; yellow arrows, antrum.

 

[UBCmed09]

That is problematic--these drugs are titrated to effect over a period of 3-4 months and the manufacturer states you have to start over if you are that far behind doses. They would have to have a PCP appointment to just figure out how to restart the med and a new Rx after surgery.

Could you (or someone) possibly share a reference for this? This seemed important to our group's recent decision to ask patients to hold semaglutide for at least 3 weeks however when I looked at the Ozempic Dosing and Administration information it actually says if a dose is missed, you can take if within 5d and otherwise just skip the dose and then return to your usual dosing regimen. Of course this document doesn't explicitly deal with situation where a patient is skipping doses for 3 weeks...

 

[chessknt]

Could you (or someone) possibly share a reference for this? This seemed important to our group's recent decision to ask patients to hold semaglutide for at least 3 weeks however when I looked at the Ozempic Dosing and Administration information it actually says if a dose is missed, you can take if within 5d and otherwise just skip the dose and then return to your usual dosing regimen. Of course this document doesn't explicitly deal with situation where a patient is skipping doses for 3 weeks...

The issue is that some people are very sensitive during titration and some arent. 2 weeks off drug puts you at 25% of the previous therapeutic level, 3 weeks half that. Telling someone to just restart at the previous dose can either do nothing or cause severe side effects. The person prescribing it will have a better idea of what to expect but the safest route would be to start over again and walk it up over a month if you haven't involved the prescriber in your pre op process. If you guess wrong it is dosed weekly and they are going to feel ****ty for the better part of that week. If you under dose they just go back to eating more so whatever I guess.

 

[dchz]

View attachment 376308​

​

​

​

Figure.​

A, Sonographic findings consistent with a “full stomach” at baseline. The antrum (evaluated in the right lateral decubitus position) contains thick fluid/solid content. B, Sonographic findings consistent with a “full” stomach 60 min after administration of domperidone. C, Sonographic findings consistent with an “empty stomach” 90 min after presentation after the administration of domperidone and erythromycin. The antrum (evaluated in the right lateral decubitus position) appears completely empty (bull’s eye pattern) with no fluid or solid content. Ao indicates aorta; L, liver; P, pancreas; Sp, spine; yellow arrows, antrum.

Bit of a nuanced question:

But I would much rather do the ultrasound in the upright position than the R lateral decubitus position. Given my understanding of anatomy, the upright position should give less false negatives compared to the R lateral decubitus position.

Am I misunderstanding the anatomy?

 

[Ronin786]

Bit of a nuanced question:

But I would much rather do the ultrasound in the upright position than the R lateral decubitus position. Given my understanding of anatomy, the upright position should give less false negatives compared to the R lateral decubitus position.

Am I misunderstanding the anatomy?

For accurate quantification of antrum size, measurements need to be obtained in the R lateral decubitus position. That's for grades 1/2. Based off the original paper and grading scale.

"Furthermore, our data suggest that the gastric antrum expands from a baseliune empty state as fluid enters the stomach, and that antral CSA as measured by ultrasonography correlates well with gastric volume in a close-to-linear manner, particularly when measured in the right lateral decubitus position. This close-to-linear relationship is limited to relatively small volumes (up to 300 ml). This is expected because the gastric antrum can only expand up to a certain limit. Volumes in excess of 300 ml result in only modest further increases in antral size, with excess volumes being accommodated by more proximal areas of the stomach. "

They also talk about gas and its significance in the supine vs lateral position.
"when the subjects move to the right lateral decubitus position the gaseous content moves away from the antrum, towards the least dependent gastric areas (body and fundus), and the fluid moves towards the more dependent antrum, facilitating the examination."

Ultrasound Assessment of Gastric Content and Volume

Background. Aspiration of gastric contents can be a serious perioperative complication, attributing up to 9% of all anesthesia-related deaths. However, there is currently no practical, noninvasive bedside test to determine gastric content and volume in the perioperative period.Methods. The...

pubs.asahq.org