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New Drugs - New Problems

Jennifer Nopoulos MSNEd, RN, CPAN

1/13/2024


The media has been recently saturated with information about new medications formulated for type 2 diabetics that are now found to be aiding in weight loss. Although one of the most popular drugs received approval in 2017, some of its untoward effects are now being linked to the drug with case studies along with FDA reports (O’Mary, 2024). The effect most concerning for peri-operative nurses is the delay of gastric emptying, which has led to emesis upon anesthesia induction or deep sedation (O’Mary 2024, Gulak & Murphy, 2023). This risk exists even with proper pre-procedure fasting (Abdelmalak & Sreedharan, 2023).


The medications in question are the glucagon-like peptide -1 (GLP-1) receptor agonists, and the sodium-glucose cotransporter 2 (SGLT2) inhibitors. The former include generic drug names such as Semaglutide (brand names Ozempic, Rybelsus, and Wegovy),  and Dulaglutide (brand name Trulicity). The later includes five different generic drugs, the most familiar being Empagliflozin (brand name Jardiance). These drugs are enthusiastically marketed, the brand names conjuring up images of happy, dancing consumers. Weight loss observations with patients have increased their use, and therefore, will increase the chance of caring for a patient who takes them.


Anesthesiologists such as Gulak and Murphy (2023) are publishing case reports of regurgitation in patients taking these drugs, including non-diabetic patients, and those with no other regurgitation risks. O’Mary (2024) counts 18 case reports of aspiration in patients taking the drugs. There will likely be no double blinded studies on this:  no one would risk patient harm in such a study, so recommendations will be derived from anecdotal reports and expert opinion (Berkow, 2023).


On the Up To Date database, Khan et al. (2023) offer the following recommendations:  with once a week Semaglutide, hold the drug for one week prior to procedure. For once-a-day Semaglutide dosing, hold the drug the day of the procedure. For SGLT2 inhibitors, discontinue use 3-4 days prior to procedure. These are conservative recommendations, as compared to some who recommend stopping Semaglutide medications four weeks prior to sedation or anesthesia (Gulak & Murphy, 2023).


For those who did not stop the drugs or for emergent procedures, Rapid Sequence Intubation (RSI), avoiding bag valve mask ventilation, is recommended (Berkow, 2023). Gastric ultrasound may be used to ascertain the need for RSI (Berkow, 2023, Crowley & Nussmeier, 2023). Communicating with those prescribing the medications is important for glucose management while the drugs are held (Berkow, 2023).


The list of high alert medications for peri-operative nurses, especially pre-admission (PATS) nurses is increasing, with varied hold recommendations that are difficult to memorize. Easy access to drug names, both generic and brand name, with recommended hold times should be made available to all peri-operative nurses. Facilities should formulate policies that will protect patients and provide staff guidance. Post op (PACU) nurses should be attentive to higher incidences of post op nausea and vomiting as well as signs of peri-operative aspiration in patients taking GLP-1 and SGLT2 medications.


References

Abdelmalak, B., & Sreedharan, R. (Oct 12, 2023). Anesthesia for patients with diabetes mellitus  

and/ or hyperglycemia. Up To Date.


Berkow, L. C. (August 1, 2023). Rapid sequence induction and intubation (RSII) for anesthesia.

Up To Date.


Crowley, M., & Nussmeier, N. A. (2023). What's new in anesthesiology. Up To Date.


Gulak, M.A., & Murphy, P. (June 6, 2023). Regurgitation under anesthesia in a fasted patient

prescribed semaglutide for weight loss:  a case report.  Canadian Journal of Anesthesia     

 

Khan, N.A., Ghali, W.A., & Cagliero, E. (Sept 30, 2023). Perioperative management of blood

glucose in adults with diabetes mellitus. Up To Date.


O’Mary, L. (Jan 5, 2024). FDA evaluating three side effects reported with weight loss

three-side-effects-reported-weight-loss-

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