Expanding the discussion on airway management with glucagon‐like peptide‐1 receptor agonist use
Year: 2025
Type: article
Abstract: We write in response to the article by Elkin et al. concerning glucagon-like peptide-1 receptor agonists (GLP-1 RAs) use and peri-operative pulmonary aspiration [1]. The authors present data that patients who are using a GLP-1 RA have a higher risk of residual gastric volume, but not an associated higher risk of aspiration. This conflicts with current anaesthesia principles for managing patients with a full stomach, including using a tracheal tube and performing rapid sequence induction (RSI) due to the assumed increased risk of aspiration. This is based on the common assumption that a full stomach is associated with an increased risk of aspiration. Adoption of new standards in the management of patients taking GLP-1 RAs that de-emphasise aspiration risk should be done cautiously, especially among patients undergoing gastrointestinal endoscopy for extended periods with an unprotected airway and who (at least in the case of colonoscopy) do not have directed suctioning of their stomach. Furthermore, Elkin et al. do not disclose the number of patients with a tracheal tube who underwent RSI, a factor that could potentially influence the risk of aspiration. Therefore, as patients on GLP-1 RAs may have increased residual gastric volumes [2], until further research indicates that GLP-1 RAs do not increase the risk of aspiration for patients undergoing procedures with unprotected airways, tracheal intubation should be considered for these patients, even when minimal nil by mouth guidelines have been met. The formation of consistent nil by mouth guidelines for GLP-1 RA usage across professional organisations is necessary. A consensus practice guideline released by professional organisations in the USA, the UK and Ireland offers excellent advice on how to clinically manage patients on GLP-1 RAs, but the nil by mouth guidelines are inconsistent with data emerging on residual gastric volume in this patient population [3, 4]. The American Gastroenterological Association released a clinical practice update that further complicates this ongoing issue, suggesting that GLP-1 RAs should not be withheld because this brings added work to nursing staff [5]. Although it is important to consider employee burnout and burden when creating clinical changes, patient safety is paramount. Furthermore, this same clinical practice update states that RSI should be performed in patients on GLP-1 RAs who have symptoms of residual gastric volume, as delaying the procedure would have negative consequences for their health. However, the authors then go on to say that RSI for endoscopies may not be possible in ambulatory or office-based settings [5]. This is particularly concerning because, regardless of patient risk, all clinical sites that perform deep sedation should be capable of undertaking RSI in case of airway emergencies. In April 2025, the Australian and New Zealand College of Anaesthetists, Australian Diabetes Society, National Association of Clinical Obesity Services and Gastroenterological Society of Australia recognised this problem and released recommendations that all patients who are on GLP-1 RAs should continue their use, maintain a clear liquid diet for 24 h and then fast for 6 h before surgery. The guidelines recommend that patients be assessed for signs or symptoms of residual gastric volume [6]. As this recommendation applies to all patients on GLP-1 RAs, it reduces confounders that impact residual gastric volume (such as duration of use and dose of drug), making it easier to make informed decisions on the day of surgery or procedure. We acknowledge that future research will be able to guide clinicians on how to manage residual gastric volume and whether it is associated with an increased risk of aspiration. Until then, we must be vigilant in taking care of this patient population while they undergo anaesthesia or sedation without a protected airway.
Source: Anaesthesia
DOI: 10.1111/anae.16676
Authors: Jenny E. Pennycuff, Katherine Hagan, Juan Cata
Institution: The University of Texas MD Anderson Cancer Center
Language: English
Subfield: Anesthesiology and Pain Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W4411737106