Aspiration risk with glucagon‐like peptide 1 ( <scp>GLP</scp> ‐1) agonists
Mincho Marroquin-Harris, Benjamin L Olesnicky
Abstract
We would like to draw attention to a concerning issue regarding the use of glucagon-like peptide 1 (GLP-1) agonists, commonly prescribed for diabetes management and weight loss, and their potential impact on gastric emptying and the associated aspiration risk. The GLP-1 agonist is an incretin, a naturally occurring peptide primarily synthesised in intestinal endocrine cells located in the terminal ileum and proximal colon. Upon nutrient ingestion, GLP-1 is rapidly released, engaging cAMP-linked GLP-1 receptors in various target tissues, including the pancreas (stimulating insulin release), the hypothalamus (stimulating satiety centres) and gastric neuronal cells (delaying gastric emptying). While endogenous GLP-1 has a short half-life of 2–3 min, pharmacological GLP-1 agonist analogues with extended durations of action have been developed for the management of diabetes mellitus (e.g. semaglutide, duraglutide, liraglutide) and weight management (e.g. semaglutide, liraglutide). Emerging evidence indicates a significant delay in gastric emptying associated with GLP-1 agonist use [1]. Furthermore, individuals with diabetes commonly experience impaired gastric emptying, with approximately 30–50% of long-standing diabetic patients exhibiting abnormally slow gastric emptying. Tachyphylaxis to delayed gastric emptying may occur with rapidly acting GLP-1 agonists administered by intravenous infusion [2]. However, there is evidence to suggest that longer acting GLP-1 agonists may impair gastric emptying for at least 8 weeks [3]. Moreover, patients utilising GLP-1 agonists for weight management may adopt intermittent drug regimens, including periods of drug ‘holidays’ between treatments. Studies suggest that both acute and intermittent use of GLP-1 agonists result in comparable impairment of gastric emptying [4]. Of particular concern to anaesthetists is the potential risk of aspiration associated with delayed gastric emptying. Several published case reports have documented instances of aspiration in patients receiving GLP-1 agonists, emphasising the importance of considering this risk [5]. However, the clinical significance of delayed gastric emptying induced by GLP-1 agonists remains incompletely understood. Additionally, the duration of the drug's effect and the timing of gastric emptying restoration following drug cessation require further investigation. Consideration should be given to performing gastric ultrasound to determine residual gastric content before induction of anaesthesia in these patients. However, it is important to note that there is currently a lack of evidence supporting the use of gastric ultrasound in this specific context. Therefore, further research efforts are warranted to elucidate the clinical significance of these effects and provide guidance on appropriate management strategies for patients receiving GLP-1 agonists who require anaesthesia and surgery.