Last year, the American Society of Anesthesiologists issued guidelines recommending preoperative withholding of GLP-1 RAs, used for type 2 diabetes (T2D) management and weight loss.
“These guidelines, which have been questioned, arose from reports of delayed gastric emptying and pulmonary aspiration following induction of anesthesia in patients using GLP-1 RAs,” according to the Stanford University School of Medicine researchers. “Although preoperative medication guidelines can prevent complications, withholding medications can also result in adverse effects. Furthermore, associated logistical burdens can result in surgical cancellations, significant care delays, and financial losses from unused operating room time.”
Those downsides are an issue with GLP-1 RAs “due to recommended withholding periods of up to a week. Given increasing use of GLP-1 RAs, larger-scale evaluations of their perioperative risks are needed,” the study team noted in the research letter published in the Journal of the American Medical Association.
Because a randomized trial of preoperative GLP-1 RA withholding was not feasible. The researchers used a claims database to evaluate the risk of postoperative respiratory complications among patients with diabetes and a prescription fill for GLP-1 RAs who underwent emergency surgery. Emergency surgery was selected because those patients would not have been able to withhold their medication in accordance with guidelines.
Specifically, the study team used administrative claims from the Merative MarketScan Commercial Database, a large national database of about 250 million individuals aged younger than 65 years enrolled in employer-sponsored health insurance plans. All patients with T2D and a GLP-1 RA prescription fill who had undergone any of 13 emergency surgeries between January 1, 2015, and December 31, 2021, were evaluated.
The sample was restricted to patients who had undergone surgery on the same day as an emergency department visit because they would not have been able to withhold their medication. “Because patients with diabetes are at higher risk of postoperative respiratory complications,” the authors noted, “our comparison group comprised patients with diabetes and at least 1 fill for a non–GLP-1 RA antidiabetic agent.”
Defined as the outcome was a composite of aspiration pneumonitis, postoperative respiratory failure, and/or admission to the ICU from 0 through 7 postoperative days.
The researchers assessed differences in characteristics between patients with versus without a GLP-1 RA fill in 23,679 patients—3,502 (14.8%) of whom had a GLP-1 RA fill. Those with a GLP-1 RA fill were more likely to be male, use more antidiabetic agents, and have diagnoses of obesity.
The results indicated that the overall incidence of postoperative respiratory complications was 3.5% for those with a GLP-1 RA fill and 4.0% for those without (odds ratio [OR], 0.85; 95% CI, 0.70-1.04; P = .12). “After adjustment, there was no significant difference in the incidence of postoperative respiratory complications between these 2 groups (adjusted OR, 1.03; 95% CI, 0.82-1.29; P = .80),” the researchers concluded.
According to the study team, limitations of the results include being restricted to commercially insured patients, being unable to measure preoperative duration of GLP-1 RA therapy, and the lack of information about patient adherence to the medication. Also, the study did not examine fills of GLP-1 RAs for weight loss alone.
“Results of this study suggest that liberalizing the withholding guidelines for GLP-1 RAs preoperatively should be considered,” the authors concluded.
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