No need for pre-endoscopy GLP-1 RA cessation: Aussie advice

Medicines

By Geir O'Rourke

18 Jun 2024

Patients taking GLP-1 receptor agonists need not discontinue their medication prior to endoscopy, but should follow a fluid diet for 24 hours before the procedure, Australian expert groups say.

The message comes amid intense debate overseas over how to manage the risk of gastroparesis with GLP-1 and GIP RAs, such as semaglutide, which slow gastric emptying.

On one side of the issue, the American Society of Anesthesiologists’ came out last June calling for patients to stop taking GLP-1 RAs prior to elective procedures and surgeries, citing anecdotal reports of an increased risk of regurgitation and aspiration of food into the airways during general anaesthesia and deep sedation.

They advised that GLP1 agonists be stopped on the day or a week prior to a procedure, depending on whether the medication is taken on a daily or weekly basis.

The society noted there were limited data on the issue, but argued the medications should be discontinued prior the procedure in view of the potential seriousness of these complications.

But muddying the waters was a statement by the American Gastroenterological Association three months later disputing that advice, instead arguing for a ‘balanced approach’ centred on standard pre-procedure fasting instructions for these patients (link here).

Now, a coalition of Australian groups have come out with their own recommendations, essentially treading a middle ground between the duelling US positions.

Described as a consensus clinical practice recommendation, rather than a guideline, the advice has been endorsed by the Australian Diabetes Society (ADS), National Association of Clinical Obesity Services (NACOS), Gastroenterological Society of Australia (GESA) and Australian and New Zealand College of Anaesthetists (ANZCA).

“The below represents a consensus based on review of currently available evidence and consensus expert opinion,” the authors stress.

“Although the current level of evidence is weak to inform a guideline, this document was written to mitigate the risk of pulmonary aspiration with the periprocedural use of GLP-1RAs/GIPRAs which, although rare, is potentially fatal.”

Regarding endoscopic procedures, the document recommends (full recommendations linked here):

  • Patients should be asked about the use of GLP-1RA and GLP-1/GIPRAs prior to undergoing endoscopic procedures.
  • There are insufficient data at this time to support the omission of GLP-1RA and GLP-1/GIPRAs prior to endoscopy.
  • All patients taking GLP-1RA and GLP-1/GIPRAs within four weeks preceding an elective upper endoscopic procedure should follow a fluid diet for 24 hours prior to endoscopy.
  • All patients taking GLP-1RA and GLP-1/GIPRAs within four weeks preceding colonoscopy should undergo routine preparation according to local practice.
  • If there are clinical concerns that retained gastric contents may be present, consider a topical anaesthesia approach minimally sedated gastroscopy (with an ultrathin 5 mm gastroscope if available) to inspect the stomach. If any solid intra-gastric contents are present, the endoscopic procedure (s) should be abandoned.

Given the recommendations are based on expert opinion, they “should not replace clinical judgement”, stress the authors, who add the advice will be reviewed in December 2024 in view of the “uncertainty of the evidence and knowledge base surrounding GLP-1 agonists in the perioperative period.

These caveats are also included in the advice with respect to anaesthesia for non-endoscopic procedures, which also note the insufficient data to support cessation of the medications prior to anaesthesia, but say it is “reasonable” to omit liraglutide (a once-daily GLP-1RA) on the day of the procedure.

On the other hand, omitting longer-acting GLP-1RA and GLP-1/GIPRAs for an extended duration may delay urgent surgery or lead to poor glycaemic control at the time of surgery with consequent risks of increased morbidity, length of stay and potentially further deceleration of gastric emptying resulting from hyperglycaemia, the authors add.

“The duration of inhibition of gastric emptying from longer acting GLP1RA and GLP-1/GIPRAs is unknown and may potentially be several weeks.”

Nevertheless, all patients taking the medications within four weeks preceding anaesthesia should be considered non-fasted and treated as such, according to the document.

Some Australian gastroenterologists have reported that even when questioned, some patients have not declared their use of GLP-1 agonists to the clinician prior to undergoing procedures, and were discovered to have retained gastric contents when undergoing an endoscopy.

Speaking at a recent limbic education event for gastroenterologists, they said the problem of undeclared GLP-1 RA use was occurring in patients using pharmacist-compounded copies of GLP-1 agonists for weight loss.

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