Recognising an increase in patients taking glucagon-like peptide 1 (GLP-1) agonists, a recent review article has underscored the importance of understanding its effects and implications for quality of care and daily practice in interventional radiology (IR). Led by Warren Clements (Alfred Health, Melbourne, Australia), the research team highlight the “urgent” need for IR-specific evidence regarding pharmacological effects and periprocedural implications in patients who take GLP-1 agonists.
Published in the Journal of Medical Imaging and Radiation Oncology, Clements and colleagues first highlight the significant growth in the use of GLP-1 agonists, referencing a report which states that overall GLP-1 agonist use has increased by over 700% among individuals without type 2 diabetes.
The authors note that GLP-1 agonists may have a positive influence on IR practice, stating that higher body mass index (BMI) is a common risk factor for increasing the rate of post-procedure complications, including impaired wound healing and thromboembolism. In reducing BMI, they note that additional practical difficulties can also be avoided such as during fluoroscopic procedures, as increased tissue thickness reduces image quality.
The authors equally present the potential downsides interventional radiologists must consider in these patients, underscoring the impact of GLP-1 agonists on fasting glucose levels. They discuss the risks of hypoglycaemia but note that, despite GLP-1 agonists’ enhancement of insulin secretion, they carry a “relatively low risk” of causing the patients to develop the condition due to their glucose-dependent mechanism.
However, the research team highlight that, in diabetic patients, the use of multi-drug anti-hyperglycaemic regimens could have implications in the periprocedural setting, with some studies suggesting increased incidence of hypoglycaemia in these patients. In their recommendation, the authors state that it may be beneficial to treat all patients taking GLP-1 agonists like regular diabetic patients, “placing them first on a morning list, when possible, to reduce prolonged and potentially unnecessary fasting”.
Continuing, the authors underscore aspiration as a potential concern when performing IR procedures for patients taking GLP-1 agonists. This relates to delayed gastric emptying when providing IR-initiated sedation, they state.
“Minimal to moderate IR-initiated sedation is often preferred and sufficient as a balance between achieving ideal analgesia and anxiolysis, while minimising the need for specialist anaesthetic support, which is not always readily available and is not always cost-effective. This approach raises concerns about the theoretical suitability of continuing GLP-1 agonists in the perioperative setting, particularly with the use of moderate sedation in an unsecured airway,” write the authors.
Further, they highlight that interventional radiologists must consider the effect on gastric emptying alongside gastric-specific procedures such as radiologically inserted gastrostomy, noting that a prolonged period of fasting may be necessary to ensure adequate gastric emptying.
They explain that, in settings where evidence is “not clear”, it is relevant to turn to society commentary to provide guidance via pooled expert consensus, yet there remains a “relative disconnect” between the service interventional radiologists provide and existing recommendations for other specialties.
“Looking forward, it is now time for the provision of IR-led evidence on the safety of using GLP-1 agonists specifically for IR procedures, so that IR societies can provide their own guidelines that are based not just on expert consensus but also relevant evidence,” the authors write. “This may require leadership from societies and eminent interventional radiologists in each region to coordinate. The importance of IR-specific guidelines cannot be overstated, as the recovery and risk profile is different from endoscopy and open surgery.”
For now, Clements et al offer three options that interventional radiologists can follow in these circumstances. Option 1—modelling care on surgical protocol that suggests ceasing subcutaneous GLP-1 agonists for seven days prior to a procedure, which the authors assign as a “conservative approach”.
Option 2 is to continue GLP-1 agonists unless performing a procedure in the gastric lumen, which is “likely to provide a more real-world approach for interventional radiologists where minimal-moderate sedation is associated with a very low background aspiration risk”, the authors write.
Finally, Option 3 is to consider a hybrid model, which is triaged based on procedure type and patient risk.
“There is no clear evidence-based answer, with studies showing positives for each option and different societies making recommendations for each. Additional universal diabetic precautions may be useful such as observation of fasting blood sugar levels in patients where medication was not ceased and performing procedures first on a morning list.
“Until a major IR society provides a consensus recommendation, interventional radiologists will have to make these decisions based on the evidence provided in this review, their own experiences, and local hospital influences.”
The authors conclude that IR-specific evidence is urgently needed regarding GLP-1 agonists and recommend that major societies take “a leadership role in promoting research” to provide clinical practice guidelines that local interventional radiologists can follow moving forward.
