Pediatric Research Update: Integrating Advocacy with Patient-Centered Care: How a Shared Decision-Making and Team-Based Approach can Improve Perioperative Period GLP-1RA Treatment Integrity

Each month, the OMA Pediatric Committee reviews a pediatric-focused obesity research update to help keep you up to date about the latest findings. This month’s article examines perioperative management of GLP-1RA therapy in adolescents, highlighting a team-based, shared decision-making approach.

Article Summary

Your Adolescent patient who has been on a GLP-1RA therapy for 6 months comes into clinic upset because his surgeon states he must stop his medication 2 weeks before getting his arthroscopic knee surgery. Stopping his GLP-1RA medication would not only disrupt continuity of treatment but also compromise his weight loss progress. In the article by Kindel et al (2024) entitled “Multisociety Clinical Practice Guidance for the safe use of Glucagon-like Peptide-1 Receptor Agonists (GLP1-Ras) in the Perioperative Period”, the authors explores a team-based, shared decision-making approach to assessing whether a patient needs to stop their GLP-1RA therapy prior to surgery. Identifying patients with GI dysmotility prior to surgery uses patient centered care, utilizing a team strategy to support the patient and their GLP-1RA therapy integrity.

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Article Review

Over the last 2 years, the treatment for adolescents who are affected with obesity has expanded with the FDA approval of anti-obesity medications and the AAP 2023 recommendations to utilize the Glucagon-like peptide-1 receptor agonists (GLP-1RAs) medications as tools to improve their weight and comorbid health concerns.

During GLP-1RA treatment, patients may need surgery for various reasons such as bariatric surgery, orthopedic surgery, endoscopy, colonoscopy, or another surgical need. In the past, it had been recommended that the patient needs to stop GLP-1RA therapy a week or two prior to surgery based on policy related to the concerns about delayed gastric emptying and concern for aspiration with anesthesia. The article by Kindel, et al (2024) describes a different approach outlining a shift in this thought to support the GLP-1RA treatment integrity in the patient’s weight loss treatment in two distinct recommendations that the team of obesity experts, surgeon, and anesthesiologist to consider.

Kindel et al (2024) identifies the GI side effects of GLP-1RAs to be concerning for GI dysmotility. Patients are at higher risk for anesthesia complications such as aspiration when they have the following symptoms: GI side effects such as abdominal pain, nausea, vomiting and constipation, reflecting possible dysmotility. The first recommendation in Kindel, et al (2024) is for the team to evaluate the patient for the variables that would increase the risk for GI dyspepsia which are: if the patient is ramping up their dose of GLP-1RA, if they are on a higher dose of GLP-1RA, if they are using a weekly dose of GLP-1RA versus a daily dose, patients that are currently having GI dysmotility symptoms, and patients having gastric emptying medical conditions such as bowel dysmotility and gastroparesis.

The second recommendation has three parts which the first part includes that if there is a concern for delayed gastric emptying in the presence of the use of GLP-1RA, one strategy the team could use is place the patient on a liquid diet 24 hours prior to surgery like in the instance of patient before they undergo a colonoscopy or bariatric surgery.

As we go throughout our day, here are some of the steps, as obesity experts, when using shared medical decision making in a team approach advocating for our adolescent patients:

1. Timing of surgery: There may need to be a discussion about when to start GLP-1RA and even to schedule the start before or after a surgery. A discussion with the Adolescent and their family when discussing starting a GLP-1RA may need to include an assessment the future role of any surgeries.
2. Timing of a GLP-1RA: If starting prior to surgery, discuss with the patient and surgeon if the surgery can be scheduled when maintenance dose is achieved. If that is not possible, then avoiding a ramp up before surgery may be prudent.
3. Assess for GI side effects: Evaluating the patients in a pre-op clinic or with the obesity specialist prior to surgery for an assessment for GI dysmotility (such as nausea, vomiting, abdominal pain, or constipation).. This patient-focused, case-by-case assessment allows the care team to identify those at higher risk of anesthesia-related complications and ensures tailored recommendations for perioperative GLP-1RA management.
4. Consult with Anesthesia Team regarding GI Side effects: if there are GI side effects, consult and communicate with the team; discuss with Anesthesia looking at the recommendations under number 2 in Kindel et al (2024) for guidance to ensure safe and best practice
5. Communication: The team would need communication with each other and the patient to assess if there must be an interruption of the GLP-1RA therapy or if the patient can continue prior to surgery and documenting this information
6. Education: working with the team and providing obesity expertise with colleagues in our health system regarding the use of GLP-1RA and the treatment modalities for adolescents.
7. Advocacy: establishing a multidisciplinary committee to develop protocols and procedures to ensure team based medical decision making to support adolescents in the weight loss treatment.

GLP-1RA therapy continuity is essential for successful weight management. Kindel, et al (2024) emphasizes a risk-based, team-centered approach in the perioperative period. Supporting them through this includes advocating for the integrity of their GLP-1RA treatment including educating patients and our colleagues on how we can work as a team for the safest and best care.