Glucagon-like Peptide-1 Receptor Agonists and Anaesthesia Considerations

The Editor, Glucagon-like peptide-1 receptor agonists (GLP-1RA) are gaining popularity for the treatment of type II diabetes mellitus and also for weight loss. Food intake stimulates the secretion of glucagon-like peptide-1 hormone which leads to the release of insulin from beta cells and inhibits glucagon secretion from the alpha cells.[1] Since GLP-1RA act only during hyperglycaemia, chances of hypoglycaemia are minimal in patients on these drugs. GLP-1RAs also delay gastric emptying which lowers the increase in blood glucose levels after food consumption. Prolonged gastric emptying also leads to increased satiety, hence decreases food consumption.[2] The cardioprotective effect of GLP-1RAs against major adverse cardiac events has been highlighted by multiple studies.[1,3] Some studies have also reported neuroprotective effect against stroke in diabetic patients.[3] Semaglutide, dulaglutide and liraglutide are some of the popularly used GLP-1 RAs. Whereas liraglutide has to be taken daily, injectable semaglutide and dulaglutide are once weekly preparations. In India, oral semaglutide is available which is prescribed as once daily dose. A sizeable number of case reports have described retention of gastric contents even beyond the prescribed preoperative fasting guidelines.[4,5] Presence of solid food in the stomach during gastrointestinal endoscopy has been reported even after 10 h of fasting in a patient on semaglutide.[5] Regurgitation of gastric contents during procedural sedation or during induction of general anaesthesia can lead to pulmonary aspiration. Pulmonary aspiration is a serious complication which can lead to morbidity and mortality. Awareness of this complication with GLP-1RAs is increasing among anaesthesiologists. American Association of Anaesthesiolgists task force has suggested that the GLP1-RA should be withheld on the day of surgery for patients taking it daily and a week before the surgery for patients taking it on a weekly basis.[6] However, if on the day of the surgery, the patient complains of bloating or nausea, the surgery should be deferred as this can be a symptom of presence of gastric contents. The Canadian Anaesthesiologists Society suggests withholding GLP1-RAs for at least three half-lives before an elective procedure.[7] If the drugs are not withheld and the surgery has to be performed, the patient should be treated as having full stomach and rapid sequence induction should be performed. The American Gastroenterology Association has suggested an individualised approach to each patient instead of blanket guidelines without sufficient data to support them.[8] Postponement of a scheduled procedure or conversion of procedural sedation to general anaesthesia are known to add to time and cost of a procedure and are often met by resistance from operative team. However, patient safety is always paramount. Preoperative gastric ultrasound can provide reliable information regarding gastric contents. It should be carried out in both supine and right lateral decubitis position to study antral cross-sectional area to determine whether stomach is empty or not and to note whether the contents are solid or liquid. Solid contents and liquids with volume more than 1.5 ml/kg are considered high risk for aspiration.[9] With introduction of this class of drugs in our country, we need to be aware of the anecdotal complications and follow best practices for patient safety. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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