New study examines whether GLP-1 RAs cause postoperative aspiration pneumonia

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) marketed in Canada include dulaglutide, liraglutide, semaglutide, and the dual glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 RA, tirzepatide. In 2024, package inserts or product monographs for several GLP-1 RAs were updated in the United States and Canada to include a warning about the possibility of pulmonary aspiration during general anesthesia or deep sedation.1Concern had been raised earlier that GLP-1 RAs are associated with delayed gastric emptying, resulting in increased residual gastric contents and adverse gastrointestinal events, such as vomiting and gastroesophageal reflux. Aspiration of gastric contents can potentially lead to severe complications, including life-threatening pneumonia.2 Several case reports have been published of pulmonary aspiration of gastric contents in patients on GLP-1 RAs undergoing general anesthesia or procedural sedation despite preoperative fasting.1 This led several organizations or experts to recommend the discontinuation of GLP-1 RAs before surgery, e.g., withholding on the day of elective surgery for GLP-1 RAs that are administered daily, or withholding for one week prior to the procedure for those administered once weekly.1,3 However, some care providers were concerned that stopping GLP-1 RA treatment could result in hyperglycemia in patients with diabetes and an increased risk of postsurgical complications, including infection.1 To further examine this issue, a US study investigated whether preoperative GLP-1 RA use is associated with postoperative aspiration pneumonia among patients undergoing common surgical procedures. According to the results of this large cohort study, the prevalence of postoperative aspiration pneumonia is not higher among patients taking GLP-1 RAs.2 The retrospective cohort study included patients who underwent one of 14 common surgical procedures over a 2.5-year period (before withholding GLP-1RAs prior to surgery was being recommended). The study excluded individuals who were younger than 18 years, underwent multiple surgical procedures, or had a preoperative history of pneumonia or acute respiratory failure in the 90-day period preceding the surgery. The primary outcome was aspiration pneumonia in the 30-day postoperative period.2 Results showed the following:The study included 366,476 patients (median age, 53 years; 56.4% women).In the cohort, 5,931 patients (1.6%) had a preoperative prescription for a GLP-1 RA.Patients taking a GLP-1 RA (compared with nonusers) were more likely to be female (59.0% vs 56.4%) and diagnosed with both obesity and diabetes (47.5% vs 6.8%).Adjusted analysis showed no significant difference between GLP-1 RA users and nonusers in the odds of postoperative aspiration pneumonia.2The investigators concluded that this cohort study found no significant association between the preoperative use of GLP-1 RAs and short-term postoperative aspiration pneumonia. They suggest that it may be beneficial to reassess guidelines for withholding GLP-1 RAs preoperatively.2Whether GLP-1 RAs should be continued or withheld prior to surgery is an important issue because GLP-1 RA use is rapidly increasing, with use for weight management, type 2 diabetes and several other potential emerging indications.In late 2024, new joint guidance from the American Society of Anesthesiologists, American Gastroenterological Association, American Society for Metabolic and Bariatric Surgery, International Society of Perioperative Care of Patients with Obesity, and Society of American Gastrointestinal and Endoscopic Surgeons states that most patients can continue taking their GLP-1 RA agonist or tirzepatide prior to elective procedures.4The joint guidance statement indicates that when there is a concern about delayed gastric emptying, patients should consume a liquid-only diet for at least 24 hours before the procedure. Point-of-care gastric ultrasound can be used on the day of the procedure to assess aspiration risk. If concern about retained gastric contents remains, rapid sequence induction of general anesthesia for tracheal intubation could be considered.4 ReferencesAnon. In brief: new FDA warning of pulmonary aspiration with GLP-1 receptor agonists. Med Lett Drugs Ther 2024 Dec 23;66(1718):201-2. (accessed March 6, 2025).Chen YH, Zink T, Chen YW, et al. Postoperative aspiration pneumonia among adults using GLP-1 receptor agonists. JAMA Network Open 2025;8(3):e250081. (accessed March 6, 2025).Institute for Safe Medication Practices Canada. Glucagon-like peptide-1 (GLP-1) receptor agonists: risk of aspiration during anesthesia. ISMP Canada Safety Bulletin 2023;23(9). (accessed March 6, 2025).Kindel TL, Wang AY, Wadhwa A, et al; American Gastroenterological Association, American Society for Metabolic and Bariatric Surgery, American Society of Anesthesiologists, International Society of Perioperative Care of Patients with Obesity, and the Society of American Gastrointestinal and Endoscopic Surgeons. Multisociety clinical practice guidance for the safe use of glucagon-like peptide-1 receptor agonists in the perioperative period. Surg Obes Related Dis 2024;20(12):1183-6. (accessed March 6, 2025).

New study examines whether GLP-1 RAs cause postoperative aspiration pneumonia

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