GLP-1 receptor agonists: confusing guidelines from ASA and FDA
Vikas O'Reilly-Shah MD, PhD, FASA
Original Article:
Larkin, M. New FDA Warning Added to Popular Weight Loss Drugs. WebMD https://www.webmd.com/obesity/news/20241106/new-fda-warning-added-popular-weight-loss-drugs
Original article
Kavarian PN, Mosher TL, Abu El Haija M. Use of glucagon-like-peptide 1 receptor agonist in the treatment of childhood obesity. Curr Opin Pediatr. 2024 Oct 1;36(5):542-546. doi: 10.1097/MOP.0000000000001379. Epub 2024 Jun 13. PMID: 39254757.
GLP-1 receptor agonists are increasingly being used in the management of type 2 diabetes and of obesity in children.1,2 This brings us to an interesting clinical question in pediatric anesthesia: do these medications meaningfully increase the risk of pulmonary aspiration? The short answer is that, yes, they likely do. The mechanism here isn’t hard to grasp. GLP-1 agonists delay gastric emptying, leading to more residual gastric contents, and thus, a theoretically higher risk of aspiration during anesthesia. But here’s the rub: we still don’t have prospective pediatric data to quantify this risk accurately.
The American Society of Anesthesiologists (ASA) has recently changed course with respect to its recommended course of action with respect to GLP-1 receptor agonists.3 Joining with other major societies, the ASA now recommends that most patients should continue taking their GLP-1 receptor agonist and that those of highest risk of GI complications should take a clear liquid diet for 24 hours prior to surgery.3 Yet, real-world practice seems to vary, and the recent FDA warning adds a new layer of attention to this already evolving practice.4 How should the presence of a GLP-1 agonist on the med list alter our perioperative induction management? Prolonged NPO times sufficient? Mask induction OK? Do we always need to place a preoperative IV? What about an RSI? What role should gastric ultrasound evaluation play?
Research has shown a clear association between GLP-1 agonists and increased residual gastric content.5 One might assume this would directly translate to an increased incidence of aspiration during anesthesia, but evidence is scant, particularly in children. Without robust, prospective data, we’re left to weigh these findings carefully and consider whether it makes sense to adopt stricter protocols universally for our pediatric patients on GLP-1s.6
Despite the unknowns, we do know that these medications, including liraglutide and exenatide, are gaining traction across the entire population including pediatrics. For adolescents with obesity or type 2 Diabetes Melitus, the benefit of GLP-1 receptor agonists appears real, with documented improvements in weight management and glycemic control. However, this growing patient demographic, now eligible for these drugs, means anesthesiologists are encountering more pediatric patients with potentially increased gastric residual volumes. For our specialty, this context is crucial in perioperative planning.
The FDA’s recent update on labeling for drugs like Ozempic and Wegovy underscores the importance of recognizing this risk in anesthesia practice. However, given the limited data specific to children, anesthesiologists and institutions are still determining how best to incorporate these new recommendations. At Seattle Children's, a cursory analysis of local data suggests that we’re not routinely implementing RSI for these patients. Is it time to change that, or does the data not yet warrant such a shift?
What do you think? Are we overestimating the aspiration risk associated with GLP-1 agonists in our pediatric patients, or is a more cautious approach warranted? As the evidence evolves, we need to stay agile in our clinical practice. If you’re routinely taking a different approach, or if this is something you’re currently wrestling with, feel free to share your thoughts with Myron who will post in a Friday reader response. We would love to hear how you and your institution are approaching this important and rapidly evolving area of concern.
PS From Myron: Confused? I know I am! Indeed, another editorial on this topic was just published in the journal Anesthesiology
Joshi GP. Preoperative Strategies for Patients on Glucagon-like Peptide-1 Receptor Agonists Navigating Current Controversies and Future Directions. Anesthesiology. 2024 Dec 1;141(6):1031-1033. doi: 10.1097/ALN.0000000000005222. PMID: 39471348.
References
1. Kavarian PN, Mosher TL, Abu El Haija M. Use of glucagon-like-peptide 1 receptor agonist in the treatment of childhood obesity. Curr Opin Pediatr 2024;36(5):542-546. (In eng). DOI: 10.1097/mop.0000000000001379.
2. Hampl SE, Hassink SG, Skinner AC, et al. Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. Pediatrics 2023;151(2) (In eng). DOI: 10.1542/peds.2022-060640.
3. American Society of Anesthesiologists. Most Patients Can Continue Diabetes, Weight Loss GLP-1 Drugs Before Surgery, Those at Highest Risk for GI Problems Should Follow Liquid Diet Before Procedure. 2024. https://www.asahq.org/about-asa/newsroom/news-releases/2024/10/new-multi-society-glp-1-guidance
4. Larkin M. New FDA Warning Added to Popular Weight Loss Drugs. WebMD. 11/06/2024 (https://www.webmd.com/obesity/news/20241106/new-fda-warning-added-popular-weight-loss-drugs).
5. Sen S, Potnuru PP, Hernandez N, et al. Glucagon-Like Peptide-1 Receptor Agonist Use and Residual Gastric Content Before Anesthesia. JAMA surgery 2024;159(6):660-667. (In eng). DOI: 10.1001/jamasurg.2024.0111.
6. Mizubuti GB, Ho AM, Silva LMD, Phelan R. Perioperative management of patients on glucagon-like peptide-1 receptor agonists. Current opinion in anaesthesiology 2024;37(3):323-333. (In eng). DOI: 10.1097/aco.0000000000001348.