To anesthetize, or not to anesthetize: a pervasive dilemma of the GLP-1 era

Since the United States Food and Drug Administration approved exenatide in 2005, it took decades for the American Society of Anesthesiologists (ASA) to identify and address perioperative safety concerns, if any, among patients using glucagon-like peptide-1 receptor agonists (GLP-1 RAs) such as exenatide. This delay could be due to several factors: GLP-1 RAs were initially used only for managing diabetes and later for obesity, and now potentially for a wide range of conditions. Additionally, the versatility of anesthesiologists in performing preoperative gastric ultrasound has seen an exponential uptick only recently. The global pandemic may have also played a role, as it restricted human movement and activities, increasing obesity rates, especially among media icons. These icons, striving to maintain societal photogenicity, experimented and succeeded with GLP-1 RAs to regain or even improve their pre-pandemic appearances. Regardless of the reasons for the rise of the GLP-1 era, the primary perioperative safety concern affecting anesthesia management is the risk of aspiration due to gastrointestinal stasis caused by GLP-1 RAs. Perioperative blood glucose management can also become problematic if diabetic patients miss their GLP-1 RA doses, whether by choice or following ASA recommendations.

The question of whether GLP-1 RAs affect procedural outcomes, such as failed or incomplete procedures, remains beyond the scope of anesthesiologists. Addressing this would require collaboration between the ASA and other societies like the American Board of Surgery (ABS), the American Society for Gastrointestinal Endoscopy (ASGE), the American Association for the Study of Liver Diseases (AASLD), the American College of Gastroenterology (ACG), and the American Gastroenterological Association (AGA) to develop multi-society consensus-based guidance. However, history suggests otherwise, as these societies have yet to collaborate on preoperative fasting guidelines in general and specifically for bowel preparation. Their contrasting statements regarding the perioperative use of GLP-1 RAs have highlighted conflicts of interest, unraveling the perioperative adversarial system. The primary questions remain: How often do patients at risk for perioperative aspiration suffer tracheobronchial aspiration events, and how often do these events become anesthesia-related morbidity-mortality claims?

There are also secondary questions to consider. Should teams use older or newer prokinetic medications perioperatively among patients using GLP-1 RAs to enhance the positive effects and mitigate the negative effects? Should they consider performing endoscopy transnasally rather than transorally to avoid anesthesia-related considerations? Could procedures be managed with non-monitored anesthesia care using moderate sedation administered by non-anesthesia personnel under the supervision of non-anesthesiologists? Should pre-sleep fasting guidelines similar to pre-anesthesia fasting guidelines be followed? Is pathological or pharmacological gastro-stasis a dysfunction of physiological gastro-stasis, where the threshold for satiety can no longer be achieved by mechanical pressure/stretch, causing gastric contents to neither move forward nor backward rapidly during sleep or under anesthesia?

Essentially, the GLP-1 era may be here to stay and grow, while the corresponding ASA guidelines for anesthesiologists may stagnate or fail unless consensus is achieved among multiple perioperative societies despite working within the perioperative adversarial system.

Deepak Gupta is an anesthesiologist.

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