The dark side of semaglutide: Gastric emptying delays pose a risk when undergoing surgery

Considered a “miracle drug,” semaglutide (also known as Ozempic and Rybelsus, among other names) has become increasingly popular due to its weight loss effects. With the praise from celebrities and billionaires along with aggressive marketing—there were over 4,000 active campaigns for the drug on Facebook and Instagram alone in June 2023—semaglutide medication prescriptions totaled more than 9 million in September 2023, an increase of 300% of prescription volume in the last three years.

Despite all of the buzz around this drug, little is still known about its long-term effects, especially how it impacts patients who are undergoing procedures or surgeries.

Potential complications

Among these concerns are delay of gastric emptying, which can be exacerbated by gastroparesis and is associated with diabetes. Gastric contents can adversely affect airway management and lead to aspiration during procedures under general anesthesia. Almost half of patients who aspirate during surgeries develop a related lung injury.

A large matched pair case-control study evaluated 1,128 individuals with diabetes who had an esophagogastroduodenoscopy between July 2020 and June 2022 and demonstrated this potential anesthetic risk. The study concluded that GLP-1 receptor agonist treatments like semaglutide were associated with gastric residue in patients with diabetes.

Similarly, another retrospective analysis of 886 patients undergoing elective upper endoscopy demonstrated that semaglutide was associated with not only increased residual gastric content but also that digestive symptoms prior to the procedure were also predictive of this outcome. This underscores the importance of further exploring the effects of GLP-1 receptor agonists in the perioperative setting.

The American Society of Anesthesiologists (ASA) recommends adults fast for ≥8 hours prior and to not consume liquids ≥2 hours prior to procedures. For children at low risk of aspiration, the ASA recommends clear fluids up to two hours prior to procedures. Despite these guidelines, there have been case reports showing that large amounts of gastric contents continue to remain during procedures.

Alarming evidence

One case report describes a 31-year-old patient with Class III obesity, hypertension, hyperlipidemia, PCOS and anxiety, who underwent an esophagogastroduodenoscopy (EGD) in preparation for bariatric surgery while taking semaglutide. Despite fasting for over 10 hours and having no complaints of gastric symptoms prior to the EGD, the procedure had to be halted because of large amounts of food in the gastric body.

Another case reported a 42-year-old patient with Barrett’s esophagus on semaglutide for two months who underwent a repeat GI endoscopy and gastric mucosal ablation. Despite having fasted for 18 hours, the procedure revealed gastric content and required suctioning before endotracheal intubation. Food remains had to be removed from the trachea and bronchi using bronchoscopy.

Revised guidelines

ASA guidelines released at the end of June 2023 now advise physicians and patients to hold GLP-1 agonists on the day of the procedure for patients who take medication daily and a week for patients who take the medication weekly. If patients experience GI symptoms on the day of the procedure, it is advised to delay the procedure. If there are no GI symptoms but the medications were not withheld, it is recommended to consider ultrasound to evaluate stomach contents or to use precautions on the assumption that the patient has a “full stomach.”

In order for semaglutide to be completely eliminated from a patient’s system, it would take around five weeks, based on semaglutide’s half-life of seven days. This brings up new questions of how glycemic control, the risk of major adverse cardiovascular events (MACE) and weight management would be impacted by this timeline.

Additionally, anesthesiologists need to be aware of alternative methods to decrease the risk of pulmonary aspiration during general anesthesia. Possible considerations include bedside ultrasound to examine gastric contents prior to surgery or use of prokinetic drugs (e.g., dopamine agonists, motilin agonists). Further investigation is required to better understand the nuanced effects of GLP-1 receptor agonists in order to provide safe and high-quality care to patients.

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