Ozempic is the brand name for semaglutide, a GLP-1 (glucagon-like peptide-1) receptor agonist used to treat type 2 diabetes and, more recently, Wegovy for obesity. The drug is administered through an injection once a week or as a once-daily pill, Rybelsus. Another similar drug that has gained popularity is tirzepatide (Mounjaro), which is a combination GLP-1 and GIP (glucose-dependent insulinotropic polypeptide) receptor agonist indicated for type 2 diabetes and Zepbound for weight loss. These drugs, originally approved for type 2 diabetes and now weight loss, lower A1c, slow digestion to increase satiety, increase fat utilization, and have led to dramatic weight loss results of around 12%–25% body weight after 52 weeks of use.1
Side effects and contraindications
Currently, patients with a history of pancreatitis, kidney disease, active gall bladder disease, medullary thyroid cancer, multiple endocrine neoplasia, and any allergy to this medicine are advised against taking these medications.2 Commonly known side effects include diarrhea, abdominal pain, constipation, nausea, gastroparesis (delayed gastric emptying), and other GI distress issues.3
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As these drugs have increased in popularity and more people are taking these medications than ever before, more side effects are being discovered.4 For example, the Food and Drug Administration (FDA) is now listing intestinal blockage on Ozempic’s warning label following 33 adverse events reported with two deaths.5Halitosis has been discussed as having the potential to be associated with these types of medications. The FDA is also evaluating reports of suicidal thoughts and hair loss (alopecia) in people taking these medications.6
Finally, based on reports of food regurgitation and aspiration during procedures involving general and deep sedation, the American Society of Anesthesiologists (ASA) has released new guidance recommending the withholding of GLP-1 receptor agonists ahead of elective procedures or surgeries.7
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The new guidance, which was composed by of members of the ASA’s Task Force on Preoperative Fasting, states:
While there is currently a lack of scientific data on how GLP-1 receptor agonists affect patients having surgery and interact with anesthesia, we’ve received anecdotal reports that the delay in stomach emptying could be associated with an increased risk of regurgitation and aspiration of food into the airways and lungs during general anesthesia and deep sedation.
Citing recent anecdotal reports purporting an association of delayed gastric emptying with use of GLP-1 receptor agonists and increased risk of regurgitation and pulmonary aspiration during general anesthesia and deep sedation, the ASA task force set forth to provide the community with guidance on scheduled elective procedures for patients who are using GLP-1 receptor agonists.
What are the guidelines for sedation?
Day(s) prior to the procedure:
- Consider holding GLP-1 receptor agonists on the day of the procedure/surgery. For patients on weekly dosing, consider holding GLP-1 receptor agonists for a week prior.
- If GLP-1 receptor agonists prescribed for diabetes management are held for longer than the dosing schedule, consider consulting an endocrinologist about bridging antidiabetic therapy to avoid hyperglycemia.
Day of the procedure:
- If gastrointestinal symptoms are present, including severe nausea/vomiting/retching, abdominal bloating, or abdominal pain, consider delaying the elective procedure and discuss the concerns of potential risk of regurgitation and pulmonary aspiration of gastric contents with the proceduralist/surgeon and the patient.
- If there are no gastrointestinal symptoms and GLP-1 receptor agonists are held as advised, proceed as usual.
- If there are no gastrointestinal symptoms, but GLP-1 receptor agonists are not held, proceed with “full stomach” precautions, or consider evaluating gastric volume by ultrasound.
- If the stomach is empty, proceed as usual.
- If the stomach is full and ultrasound is inconclusive or not possible, consider delaying the procedure or treat the patient as “full stomach” and manage accordingly. Discuss the concerns about potential risk of regurgitation and pulmonary aspiration of gastric contents with the anesthesiologist/surgeon and the patient.
The task force highlighted there is no evidence for the optimal duration of fasting for patients on GLP-1 receptor agonists and suggests following current ASA fasting guidelines until adequate evidence exists.
Editor’s note: This article originally appeared in Perio-Implant Advisory, a chairside resource for dentists and hygienists that focuses on periodontal- and implant-related issues. Read more articles and subscribe to the newsletter.
References
- Aronne LJ, Sattar N, Horn DB, et al. Continued treatment with tirzepatide for maintenance of weight reduction in adults with obesity: the SURMOUNT-4 randomized clinical trial. 2024;331(1):38-48. doi:10.1001/jama.2023.24945
- Singh S, Chang HY, Richards TM, Weiner JP, Clark JM, Segal JB. Glucagonlike peptide 1–based therapies and risk of hospitalization for acute pancreatitis in type 2 diabetes mellitus: a population-based matched case-control study. JAMA Intern Med.2013;173(7):534-539. doi:10.1001/jamainternmed.2013.2720
- Smits MM, Van Raalte DH. Safety of semaglutide. Front Endocrinol (Lausanne). 2021;12:645563. doi:10.3389/fendo.2021.645563. Erratum in: Front Endocrinol (Lausanne). 2021;12:786732. doi:10.3389/fendo.2021.786732
- Shu Y, He X, Wu P, Liu Y, Ding Y, Zhang Q. Gastrointestinal adverse events associated with semaglutide: a pharmacovigilance study based on FDA adverse event reporting system. Front Public Health. 2022;10:996179. doi:10.3389/fpubh.2022.996179
- O’Mary L. FDA adds warning of intestinal blockages to Ozempic label. WebMD. https://www.webmd.com/obesity/news/20230928/risk-of-intestinal-blockage-added-to-ozempic-label
- O’Mary L. FDA evaluating three side effects reported with weight loss drugs. Medscape. January 5, 2024. https://www.medscape.com/s/viewarticle/fda-investigates-three-side-effects-reported-weight-loss-2024a10000e4
- Joshi GP, Abdelmalak BB, Weigel WA, et al. American Society of Anesthesiologists consensus-based guidance on preoperative management of patients (adults and children) on glucagon-like peptide-1 (GLP-1) receptor agonists. American Society of Anesthesiologists. June 29, 2023. Accessed July 13, 2023. https://www.asahq.org/about-asa/newsroom/news-releases/2023/06/american-society-of-anesthesiologists-consensus-based-guidance-on-preoperative
Scott Froum, DDS, a graduate of the State University of New York, Stony Brook School of Dental Medicine, is a periodontist in private practice at 1110 2nd Avenue, Suite 305, New York City, New York. He is the editorial director of Perio-Implant Advisory and serves on the editorial advisory board of Dental Economics. Dr. Froum, a diplomate of both the American Academy of Periodontology and the American Academy of Osseointegration, is a volunteer professor in the postgraduate periodontal program at SUNY Stony Brook School of Dental Medicine. He is a PhD candidate in the field of functional and integrative nutrition. Contact him through his website at drscottfroum.com or (212) 751-8530.
