Perioperative Management of Patients Taking Glucagon-Like Peptide-1 Receptor Agonists - A Survey of Knowledge and Current Practices Among Indian Anesthesiologists

The prevalence of type 2 diabetes mellitus (T2 DM) and obesity is rapidly increasing worldwide, including in India. Glucagon Like peptide-1 receptor agonists (GLP-1 RAs) have emerged as a cornerstone of pharmacological therapy for T2 DM, offering effective glycemic control and additional benefits such as weight reduction and cardiovascular risk mitigation. As a result of its efficacy in weight reduction, GLP-1 RA are now being used for weight loss in obese patients to avoid the need for bariatric surgery. As more patients start taking these drugs, their use will become increasingly common in patients presenting for surgical procedures.

GLP-1 RAs exert their therapeutic effects by mimicking the endogenous GLP-1 hormone, which stimulates insulin secretion, suppresses glucagon release, and slows gastric emptying. While these actions are beneficial for glycemic control, they pose unique challenges in the perioperative period. Delayed gastric emptying, a prominent effect of GLP-1 RAs, increases the risk of pulmonary aspiration, particularly in patients undergoing general anaesthesia. Furthermore, the insulinotropic effects of these agents can lead to hypoglycemia, especially in the context of perioperative fasting and stress.

Recognizing these potential complications, several professional organizations, including the American Society of Anesthesiologists (ASA) and the Australian and New Zealand College of Anaesthetists (ANZCA) have published guidelines regarding the perioperative management of patients taking GLP-1 RAs. These guidelines generally recommend withholding short-acting GLP-1 RAs on the day of surgery and withholding long-acting GLP-1 RAs for a longer period before surgery. However, the optimal management strategy remains debatable, and adherence to these guidelines in clinical practice is not uniformly established. Guidelines recommend development of multidisciplinary protocols individualised with patient risk. The safe use of GLP-1RA should include efforts to minimise the aspiration risk due to delayed gastric emptying. This can be achieved by preoperative diet modification and/or altering anaesthesia plan to consider rapid sequence induction of general anaesthesia for tracheal intubation.

In India, where the prevalence of obesity and T2 DM is exceptionally high, the perioperative management of patients taking GLP-1 RA is of paramount importance. At present, Semaglutide and Tirzepatide are not available in India. However, over time these drugs will become more popular amongst people struggling with weight loss and Indian anaesthesiologists will encounter these patients when they come for surgical procedures. Variations in clinical practice, access to resources, and awareness of international guidelines may influence the perioperative management of these patients. At present, there is a paucity of data regarding the level of knowledge and current practices of Indian anesthesiologists in this area.  Understanding the current practices and identifying potential knowledge gaps among Indian anesthesiologists is crucial for improving patient safety and avoiding complications.

This study aims to address this critical knowledge gap by conducting a national survey of Indian anesthesiologists to assess their current knowledge and practices regarding the perioperative management of patients taking GLP-1 RAs. The findings of this study will provide valuable insights into the current state of practice in India and inform the development of evidence-based strategies to optimize perioperative care for this growing patient population. By evaluating the awareness and application of existing guidelines, this research will contribute to the enhancement of patient safety and the promotion of standardized, best-practice approaches within the Indian anesthesia community.