Keith Chamberlin, MD, MBA, FASA
First things first – I am a board-certified anesthesiologist practicing in a local community hospital. In a previous life I was the Vice Chair of the LPAD, and served as the head for the Practice Affairs division. I guess the fire never goes away fully.
Now I am caught up in the latest controversy about the use of GLP-1s, and timing of elective surgery. That is, caught in the middle between GI docs and surgeons who want to proceed despite (or because of…) the latest (and most confusing to me) ASA recommendations for delaying surgery.[1] [2] Which conflicted with the previous ASA recommendations for delaying surgery.[3] I am not going to review the pharmacology of GLP-1 drugs, I am talking what to do in the private practice situation!
My group, like I believe many of yours, set a policy to delay surgery for at least 7 days after a patient took an injectible GLP-1. This caused some havoc when the policy first came out, but everyone got used to it and postponed surgeries for the most part dwindled to zero. Then the new guidelines came out, and surgeons and GI docs and medical newsletters and periodicals and widespread media jumped on the single line that said: “ Most patients should continue taking their glucagon-like peptide-1 (GLP-1) receptor agonists before elective surgery.”[4] [5] [6] Of course they ignored the rest of the statement like escalating doses, GI symptoms, any other cause of gastroparesis, and in general a good overall evaluation of the patient and their medical readiness for surgery.
And the discussion continues now with a study about a 14 day hold on these meds.[7] And where does gastric ultrasound fit in?[8] What is a private practitioner to do? What is best for these patients – particularly those who have had a bowel prep, or those who are diabetic and have blood sugar at risk? And what if you do not have a separate preop clinic? What if you find out the day of surgery that the meds have not been discontinued? Let me give you a real-life example: I had a patient on Tirzepatide, which is more than a single drug GLP-1. It has GLP-1 and a GIP drug (glucose dependent insulinotropic polypeptide.). He was scheduled for a procedure involving a gastroscope (being obtuse here to avoid any patient identification…) I called him the night before, saw he took Tirzepatide, and he relayed he had his last dose on Sunday, and this was going to be a Tuesday procedure. I calmly and thoroughly explained the risks and that we could not go ahead with his procedure until at least 7 days passed between the last dose and his procedure. What was his response: thank you doctor for catching this.
I called the proceduralist – he said can’t you just give him some Versed and we can do it? That answer was no. He was upset, the surgery schedulers were upset and the anesthesia schedulers took it in stride. You know who was not upset? The patient. 15 minutes after I made that decision the case had been rescheduled, the proceduralist got to start his to follow case earlier, and the patient had a nice dinner and headed home.
Private practice anesthesiology can be a lonely profession. The production pressure, the political pressure (local – surgeon preference, etc.), and the always in the back of your mind medical liability pressure can make life stressful. Doing the right thing for the reason can alleviate much of that pressure. If you think it is lonely in the OR, try it in the legal process.
I am interested in your opinion: what do you and what does your group do about GLP-1 and timing of surgery? How much push back do you get? How have the recommendations cited in this post made a difference in how you treat these patients?
Oh, and by the way, I am on Tirzepatide and feel full most of the time. The drugs work…
[1] https://www.asahq.org/about-asa/newsroom/news-releases/2024/10/new-multi-society-glp-1-guidance
[2] Anesthesiology 141(6):p 1208-1209, December 2024.
[3] Joshi GP, Abdelmalak BB, Weigel WA, et al.: American Society of Anesthesiologists consensus-based guidance on preoperative management of patients (adults and children) on glucagon-like peptide-1 (GLP-1) receptor agonists. Available at: https://www.asahq.org/about-asa/newsroom/news-releases/2023/06/american-society-of-anesthesiologists-consensus-based-guidance-on-preoperative.
[4] https://www.webmd.com/obesity/news/20241112/new-guidance-for-patients-taking-glp-1-drugs-before-surgery
[5] https://www.houstonmethodist.org/leading-medicine-blog/articles/2024/jul/study-challenges-seven-day-hold-on-glp-1-agonists-before-surgery/
[6] https://www.usnews.com/news/health-news/articles/2024-10-31/most-patients-can-keep-using-glp-1-weight-loss-meds-before-surgeries
[7] https://dgnews.docguide.com/article/cessation-of-glp-1-ras-less-than-7-days-prior-to-total-knee-hip-replacement-increases-complications
[8] https://www.asahq.org/podcasts/central-line/episode-one-hundred-twenty-six