New GLP-1 Study

[BobLoblaw78]

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Here is a article from AJG that you will probably hear about. I always like to have a heads up on what is going to be thrown in my face. I like how they state that a 45% increase in emptying time is not significant. I'm not sure I trust patients with 24 hours of liquids only when it comes to aspiration versus just a bad prep. I didn't get to read the full article/study. If any one else sees GIGO points, please add to it (N, retrospective, etc).

 

[Iso4ane]

45% increase in emptying time, I guess at minimum we should increase NPO times by 50% then….
EDIT: Especially since a 50% increase in time is not significant.

 

[coffeebythelake]

Doesn't matter. Unless ASA change their guidelines that's what I'm sticking to

 

[cytocide]

Is this it?:

Quantified Metrics of Gastric Emptying Delay by... : Official journal of the American College of Gastroenterology | ACG

sms of weight loss and to periprocedural management of GLP-1 RA. We hypothesized that the magnitude of gastric emptying delay would be low and of limited clinical significance to procedural sedation risks. METHODS: A protocolized search identified studies on GLP-1 RA that quantified gastric...

journals.lww.com

Just to be safe - NPO 7 days.

 

[BobLoblaw78]

Is this it?:

Quantified Metrics of Gastric Emptying Delay by... : Official journal of the American College of Gastroenterology | ACG

sms of weight loss and to periprocedural management of GLP-1 RA. We hypothesized that the magnitude of gastric emptying delay would be low and of limited clinical significance to procedural sedation risks. METHODS: A protocolized search identified studies on GLP-1 RA that quantified gastric...

journals.lww.com

Just to be safe - NPO 7 days.

Yes. That is it. Sorry about not posting- thought I had.

 

[Beeftenderloin]

Was just having an interesting conversation with a colleague the other day. Patient scheduled for elective surgery on Tuesday. Takes their ozempic on Tuesday. Took it the week prior (on Tuesday) then mistakenly took it again the morning of surgery (Tuesday). Sub-cue injection takes a full 24hrs to reach peak plasma concentration. They considered proceeding because based on drug kinetics, they basically followed guidelines, but ultimately opted to cancel/reschedule because it was purely elective and went against ASA guidelines by the letter.

This just further illustrated to me how stupid/inadequate the ASA guidelines are for these drugs.

Edit: If there’s enough residual drug left on day 7 to allow 24 hours for the drug to reach peak plasma concentration, theirs still must be enough drug floating around to give good clinical effect during that 24hrs immediately following the injection. Meaning that once drug has reached steady state, it’s must still be having good clinical effect, even 7 days since last injection, otherwise it would need to be dosed more frequently.

 

[Sriddymopboi]

Was just having an interesting conversation with a colleague the other day. Patient scheduled for elective surgery on Tuesday. Takes their ozempic on Tuesday. Took it the week prior (on Tuesday) then mistakenly took it again the morning of surgery (Tuesday). Sub-cue injection takes a full 24hrs to reach peak plasma concentration. They considered proceeding because based on drug kinetics, they basically followed guidelines, but ultimately opted to cancel/reschedule because it was purely elective and went against ASA guidelines by the letter.

This just further illustrated to me how stupid/inadequate the ASA guidelines are for these drugs.

Edit: If there’s enough residual drug left on day 7 to allow 24 hours for the drug to reach peak plasma concentration, theirs still must be enough drug floating around to give good clinical effect during that 24hrs immediately following the injection. Meaning that once drug has reached steady state, it’s must still be having good clinical effect, even 7 days since last injection, otherwise it would need to be dosed more frequently.

Half life is 7 days. Takes 5 half lives for the drug to be out of the system. Ergo, holding for 7 days makes no sense, because half of the drug is still in the body, having an effect.

 

[deleted87051]

Is this it?:

Quantified Metrics of Gastric Emptying Delay by... : Official journal of the American College of Gastroenterology | ACG

sms of weight loss and to periprocedural management of GLP-1 RA. We hypothesized that the magnitude of gastric emptying delay would be low and of limited clinical significance to procedural sedation risks. METHODS: A protocolized search identified studies on GLP-1 RA that quantified gastric...

journals.lww.com

Just to be safe - NPO 7 days.

If they’ve been NPO for 7 days, I’m fine with continuing the Ozempic 😉

 

[coffeebythelake]

Half life is 7 days. Takes 5 half lives for the drug to be out of the system. Ergo, holding for 7 days makes no sense, because half of the drug is still in the body, having an effect.

Well it's not just as simple as that. The guideline is for any dose of glp-1 from starter dose 0.25 mg ozempic to 2 mgozempic.

 

[BobBarker]

the GLP1’s have “legs” for at least 14 days if the patient has been taking it routinely at 7 days.

 

[dannyboy1]

There is tachyphylaxis according to the studies. After 20 weeks of use gastric emptying essentially goes back to normal. Having used this drug I can attest that it seems accurate.

 

[sloh]

There is tachyphylaxis according to the studies. After 20 weeks of use gastric emptying essentially goes back to normal. Having used this drug I can attest that it seems accurate.

Your appetite also returns?

 

[dannyboy1]

Your appetite also returns?

My experience was that around the 6 week mark, when I was on the 0.5 dose was the low point for my appetite. I literally could not finish 2 rolls of sushi. Slowly everything starts coming back. The GI seems to go back to normal but there is definitely less desire to eat overall. I maxed out on a dose of 1 because I hit my goal. Maintaining now on .5 every 2 weeks.

 

[sloh]

My experience was that around the 6 week mark, when I was on the 0.5 dose was the low point for my appetite. I literally could not finish 2 rolls of sushi. Slowly everything starts coming back. The GI seems to go back to normal but there is definitely less desire to eat overall. I maxed out on a dose of 1 because I hit my goal. Maintaining now on .5 every 2 weeks.

Thanks. I don’t think GLP-1 agonists have been out on the market long enough for tachyphylaxis to have occurred in noticeable numbers. I did read about this tachyphylaxis issue early on though. Seems like even for patients willing to take GLP-1 agonists for life, it’s a temporary solution.

 

[Hoya11]

Thanks. I don’t think GLP-1 agonists have been out on the market long enough for tachyphylaxis to have occurred in noticeable numbers. I did read about this tachyphylaxis issue early on though. Seems like even for patients willing to take GLP-1 agonists for life, it’s a temporary solution.

Many believe this is only a temporary fix but have we really seen someone who lost a lot of weight put it right back on ? The people I know who lost weight on it are still keeping it off.

 

[deleted1183938]

My experience was that around the 6 week mark, when I was on the 0.5 dose was the low point for my appetite. I literally could not finish 2 rolls of sushi. Slowly everything starts coming back. The GI seems to go back to normal but there is definitely less desire to eat overall. I maxed out on a dose of 1 because I hit my goal. Maintaining now on .5 every 2 weeks.

So… did you experience the queiting of the “food noise” by chance? If you ever had food noise that is?

 

[dannyboy1]

So… did you experience the queiting of the “food noise” by chance? If you ever had food noise that is?

Yes. Just no desire to snack all the time.

 

[deleted1183938]

Yes. Just no desire to snack all the time.

What exactly is food noise. Just constantly thinking about food all the time? Next meal, next snack, last meal, tomorrow’s meal, yesterday’s meal what???
Even where you have eaten and are full?

 

[dannyboy1]

What exactly is food noise. Just constantly thinking about food all the time? Next meal, next snack, last meal, tomorrow’s meal, yesterday’s meal what???
Even where you have eaten and are full?

Yup. Also not as hungry all the time.

 

[deleted1183938]

Yup. Also not as hungry all the time.

Even AFTER you have eaten and are full? Is it guilty thought at this point?

 

[caligas]

colonoscopy and they had Ozempic 10 days ago. No US available.

IV sedation or tube?

 

[abolt18]

colonoscopy and they had Ozempic 10 days ago. No US available.

IV sedation or tube?

Propofol sedation in my hands. Patient should be NPO to food for several days which in my mind totally negates the concern about gastric emptying time and ozempic timing.

 

[caligas]

Propofol sedation in my hands. Patient should be NPO to food for several days which in my mind totally negates the concern about gastric emptying time and ozempic timing.

Ours are not NPO for several days

Maybe one

 

[okayplayer]

IVGA/MAC and a carefully worded note/discussion citing ASA guidelines being in favor of proceeding. I also tell them they are more likely to have recall of the procedure because if they start coughing, etc I will lighten the sedation. I have a dot phrase that is a copy/paste of the ASA recommendation.

 

[caligas]

IVGA/MAC and a carefully worded note/discussion citing ASA guidelines being in favor of proceeding. I also tell them they are more likely to have recall of the procedure because if they start coughing, etc I will lighten the sedation. I have a dot phrase that is a copy/paste of the ASA recommendation.

OK, devils advocate here. I can’t stand doing ET tube for endoscopy so I really am on your side.

1) I believe the guidelines are just to tell you how long to hold the medication they don’t speak to what type of anesthetic we would use so I could still be criticized for not securing the airway, even if we were within the guidelines recommendations

2) my personal belief is that when it comes to an unsecured airway, the deeper the sedation, the better in terms of reducing risk of aspiration. I think this is counterintuitive for a lot of people, but the reality is people that are light cough, and people that cough bring stuff up out of their stomach.

 

[okayplayer]

OK, devils advocate here. I can’t stand doing ET tube for endoscopy so I really am on your side.

1) I believe the guidelines are just to tell you how long to hold the medication they don’t speak to what type of anesthetic we would use so I could still be criticized for not securing the airway, even if we were within the guidelines recommendations

2) my personal belief is that when it comes to an unsecured airway, the deeper the sedation, the better in terms of reducing risk of aspiration. I think this is counterintuitive for a lot of people, but the reality is people that are light cough, and people that cough bring stuff up out of their stomach.

Agree, but if they start coughing in this scenario I will lighten them up as I’m suctioning oropharynx, etc. This is what I’m consenting them for.

If you have a very good GI doc and a reasonable patient, an alternative here is to do RN sedation for this case.

As to point 1, I’m sure you are right some “expert” would say you should have intubated the outpatient colonoscopy at the freestanding GI ASC. But I would say the majority of your peers would say you were practicing at the standard of care by holding the GLP-1 as per ASA practice guidelines and doing the customary anesthetic for the procedure (as in 99.9+% of patients have MAC/IVGA for a colo).

 

[BLADEMDA]

Agree, but if they start coughing in this scenario I will lighten them up as I’m suctioning oropharynx, etc. This is what I’m consenting them for.

If you have a very good GI doc and a reasonable patient, an alternative here is to do RN sedation for this case.

As to point 1, I’m sure you are right some “expert” would say you should have intubated the outpatient colonoscopy at the freestanding GI ASC. But I would say the majority of your peers would say you were practicing at the standard of care by holding the GLP-1 as per ASA practice guidelines and doing the customary anesthetic for the procedure (as in 99.9+% of patients have MAC/IVGA for a colo).

I totally agree with your post. But, let me tell you how things will go in the Legal world:

They hire an expert who is paid by the plaintiff's lawyer. He/She will say almost anything to get his/her $10,000 fee. This means their expert will claim you should have intubated the patient and avoided the death of Mr. Smith. Mr. Smith ended up with an aspiration pneumonia followed by ARDS then renal failure then death. Mr. Smith's wife is suing for $5 million dollars. Your insurance carrier is wary of going to court knowing that an intubation with an ET tube would have prevented this complication then death. If the insurance carrier loses the case the jury verdict is likely to exceed $5 million if not $10 million.
Both sides agree to settle the case for $700,000.