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Drs Akshay Jain and Girish Joshi discuss clinical considerations to keep in mind when someone on GLP-1 therapy is undergoing elective procedures. https://www.medscape.com/viewarticle/glp-1-guidance-reduce-regurgitation-and-aspiration-risk-2024a1000d35?src=soc_yt -- TRANSCRIPT -- Akshay B. Jain, MD: Welcome back to ADA 2024 updates. I'm endocrinologist Dr Akshay Jain from Vancouver in Canada, and today we've got a very special guest. We've got Professor Dr Girish Joshi. Dr Joshi is a professor of anesthesiology and pain medicine at UT Southwestern in Dallas, Texas. He was one of the speakers at a very impactful session that was talking about the postoperative and intraoperative considerations for people who are on GLP-1 therapy. He's here to talk with us about clinical considerations that one needs to keep in mind when someone on glucagon-like peptide 1 (GLP-1) receptor agonist therapy is undergoing elective procedures. Welcome, Dr Joshi. Girish P. Joshi, MD: Thank you, Akshay. It's an honor. Jain: I was attending your session, and I found it very clinically impactful. This is something that we are seeing more and more in clinical practice. For our viewers today, can you share with us, as an anesthesiologist, the potential risks for aspiration and the rates of aspiration that you're seeing in people who are on GLP-1 therapy? Joshi: We don't know the exact rate of aspiration with GLP-1 therapy because there are no good studies, but there are several anecdotal reports, including several personal communications where people have contacted me and the American Society of Anesthesiologists (ASA). I'm the chair of the task force for these GLP-1 recommendations developed by the ASA. To give an example, one of the cases reported to me was from a colleague in Dallas where a patient, otherwise completely healthy, came in for a shoulder arthroscopy — a simple outpatient procedure in a freestanding ambulatory surgery center. Surgery went fine. At the end of the procedure, she regurgitated gastric content and aspirated, and then had to be taken to the intensive care unit (ICU) and she spent 7 days in the ICU. Retrospectively, it was recognized that she was on GLP-1 therapy for weight loss, which was not disclosed. This was just before the ASA came up with the guidance, basically, so people didn't know that GLP-1 receptor agonists do increase the risk for aspiration. Jain: That's a really good point straight from your clinical practice. For our viewers who may not be familiar with the guidelines, could you tell us, in a nutshell, for people on GLP-1 therapy who are going in for an elective procedure that requires general anesthesia, what would be the recommendations for holding GLP-1s? Joshi: I have to first emphasize that currently, the evidence to provide any guidance is sparse, and whatever studies are available are basically questionable or of poor quality. With that said, the reason why the ASA came up with the guidance was to inform our colleagues, anesthesiologists, as well as our colleagues from surgery and other proceduralists of this concern about increased regurgitation and aspiration in patients on GLP-1 receptor agonists. That was the primary aim. Because the evidence is sparse, we basically came up with different approaches to decrease or mitigate the risk for regurgitation and aspiration. It starts with having a collaborative discussion, including the patients, or shared decision-making with the physicians and the patient regarding the potential risks, so mention to the patient that there is a potential risk. Then, avoid the elective procedures in patients at high risk. Examples of patients at high risk would be those who are basically in the escalation phase of the GLP-1 therapy, patients with prior history of gastroparesis, or patients on drugs that can cause gastroparesis. I don't know whether you remember I had an algorithm I developed and presented at the American Diabetes Association (ADA) meeting, where I presented the potential risk factors. If the patients are at risk for regurgitation and aspiration, that's the patient population we've got to be extra careful with. Maybe start off withholding the drug if the patients are on, say, a weekly therapy, then 1 week before, though the evidence is minimal. Nevertheless, more importantly, avoid elective procedures during that escalation phase in this patient population. Transcript in its entirety can be found by clicking here: https://www.medscape.com/viewarticle/glp-1-guidance-reduce-regurgitation-and-aspiration-risk-2024a1000d35?src=soc_yt
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