Glucagon‐like peptide‐1 receptor agonists: a narrative review of clinical pharmacology and implications for peri‐operative practice

Summary Background Glucagon‐like peptide‐1 receptor agonists are used increasingly in the management of patients living with type 2 diabetes mellitus and obesity. In patients using glucagon‐like peptide‐1 receptor agonists, a key concern in the peri‐operative period is the increased risk of pulmonary aspiration due to delayed gastric emptying. This review provides an overview of the pharmacodynamic and pharmacokinetic properties of glucagon‐like peptide‐1 receptor agonists and the risk of delayed gastric emptying and aspiration. Methods We conducted searches of MEDLINE and EMBASE databases of articles published before January 2024 using the keywords and medical subject headings: incretins; glucagon‐like peptide‐1; GLP‐1; glucagon‐like peptide‐1 receptor agonists; GLP‐1 RA; peri‐operative period; perioperative; peri‐operative; stomach emptying; gastric emptying; pulmonary aspiration; aspiration; food regurgitation; and regurgitation. The evidence was analysed, synthesised and reported narratively. Results A total of 1213 articles were located after duplicates were removed. Two authors screened the titles and abstracts to identify those studies which assessed specifically the risk of delayed gastric emptying and pulmonary aspiration or regurgitation in the peri‐operative period. We searched manually the reference lists of relevant studies to identify any additional case reports. Ten studies were identified. Available evidence was limited to case reports, case series and observational work. Conclusions There is insufficient evidence to put forward definitive guidance regarding the ideal cessation period for glucagon‐like peptide‐1 receptor agonists before elective surgery. Precautionary practice is required until more evidence becomes available. We suggest an individualised, evidence‐based approach. In patients living with type 2 diabetes mellitus, there is concern that prolonged cessation before surgery will have a detrimental effect on peri‐operative glycaemic control and discussion with an endocrinologist is advised. For patients taking glucagon‐like peptide‐1 receptor agonists for weight management, these drugs should be withheld for at least three half‐lives before an elective surgical procedure.