3 April 2025 Explanatory notes 1. Patients should be asked about the use of GLP-1RA and GLP-1/GIPRAs prior to undergoing anaesthesia or sedation. The patient, prescribing clinician, proceduralist or surgeon and the anaesthetist should be involved with discussions regarding planning for the procedure, including risks and benefits of withholding therapy and those of alternative and mitigating strategies [2]. a. Elective preprocedural cessation of GLP-1RA and GLP-1/GIPRAs is not recommended. Currently, there are insufficient data to support the cessation of GLP-1RA and GLP-1/GIPRAs prior to anaesthesia [2]. Omission of longer-acting GLP-1RA and GLP-1/GIPRAs for 1-2 weeks is unlikely to alter gastric emptying. Omission for an extended duration may delay urgent surgery or lead to poor glycaemic control at the time of surgery with consequent risks of increased morbidity, length of stay and potentially further deceleration of gastric emptying resulting from hyperglycaemia. Substitution of a different class of glucose-lowering drug for several weeks is often very challenging. Omission of therapy for prolonged periods may compromise weight control where patients are taking GLP1RAs and GLP-1/GIPRAs for this indication. It is also recommended that GLP-1RAs with a shorter half-life (i.e. liraglutide) be continued. In individual circumstances, withholding liraglutide for 3 to 4 days may be considered, however, this may have implications for glycaemic control and weight management. There is no current evidence to support any added safety benefits of this practice. The duration of inhibition of gastric emptying from longer acting GLP-1RA and GLP-1/GIPRAs is unknown and may potentially be several weeks. It has been widely assumed that longer-acting GLP-1RAs do not slow gastric emptying with sustained administration because of tachyphylaxis. This assumption is not supported by existing evidence. The three longer-acting GLP-1RAs that have been assessed using scintigraphy, the ‘gold-standard’ method for quantifying gastric emptying - liraglutide [3-5], exenatide QW [6] and semaglutide sc (1.0 mg/wk) [7] – have been shown to slow gastric emptying with sustained administration of 8 – 16 weeks duration. Further studies, using appropriate methods, to characterise the effect of long-term administration of longer-acting GLP-1RAs and GLP-1/GIPRAs on gastric emptying are a priority. b. Absence of symptoms is an unreliable indicator of gastric emptying The relationship between upper gastrointestinal symptoms (nausea and vomiting) and slowing of gastric emptying by GLP-1RAs is weak. The majority of studies that have evaluated the relationship between the effects of GLP-1RAs on gastric emptying and gastrointestinal symptoms in health, obesity, or T2D found no or low correlations [8-10]. A recent retrospective study of 404 patients undergoing elective oesophagogastroduodenoscopy found an association of semaglutide use with both the presence of preoperative digestive symptoms (nausea/vomiting, dyspepsia, abdominal distension) and residual gastric content, however numbers were small [11]. Based on these limited data, the presence of gastrointestinal side effects is not a reliable indicator of the degree of slowing of gastric emptying. c. Incidental interruption of therapy Given possible supply issues, GLP-1RA and GLP-1/GIPRA therapy may have been interrupted due to lack of availability. If GLP-1RA and GLP-1/GIPRA therapy has been interrupted for 4 elimination half-lives or more (see Table 1) it may be assumed that the effect of the medication on gastric emptying is no longer present. Table 1: GLP-1 RAs and Dual GLP-1 and GIP co-agonists registered for use in Australia Agent Receptor agonism Elimination half-life Administration schedule Trade name Liraglutide GLP-1 12.6 – 14.3 hours Once daily Victoza (up to 1.8 mg) Saxenda (up to 3.0 mg) Dulaglutide GLP-1 4.7 – 5.5 days Once weekly Trulicity Semaglutide GLP-1 5.7 – 6.7 days Once weekly Ozempic (up to 1 mg) Wegovy (up to 2.4 mg) Tirzepatide GLP-1 & GIP 4.2 – 6.1 days Once weekly Mounjaro
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