The weight loss drug craze of the last couple of years brings important considerations for otolaryngologists, including how to manage gastric emptying before procedures for patients taking the medications and the possibility of the drugs being a new option for obstructive sleep apnea patients, an expert speaker said at this year’s Triological Society Combined Sections Meeting.
The medications—mainly semaglutide, a glucagon-like peptide 1 (GLP1) receptor agonist, and tirzepatide, a GLP-1/glucose-dependent insulinotropic polypeptide (GIP) receptor—have been a revelation for people looking to lose weight. Due to popularity fueled by celebrity use and social media influencers, more than 9 million prescriptions for semaglutide were filled in the last three months of 2022. The number of prescriptions has increased by 300% since 2020 and is still rising, and the drug has become difficult to obtain even for those who need it for diabetes, said Ramzi Younis, MD, a professor of otolaryngology at the University of Miami in Coral Gables.
Semaglutide, originally approved for diabetes and marketed as Ozempic, is now marketed as Wegovy at a different dose for weight loss. Studies found that more than 50% of users achieved a weight loss of at least 15%. Tirzepatide, marketed as Mounjaro and approved by the FDA in May 2022, produced more than 20% weight loss in 57% of patients. Some of the most common side effects seen for semaglutide and tirzepatide are nausea, vomiting, abdominal pain, and constipation and gastroparesis.
Unfortunately, there’s no evidence to suggest what the optimal duration for fasting is for these patients. — Ramzi Younis, MD
The drugs work by delaying gastric emptying, which helps diabetes patients by reducing the rate at which glucose enters the circulation after meals. This slowed gastric emptying also dampens appetites, helping people lose weight.
In otolaryngology, this effect can cause problems with certain procedures. There have been many case reports in which patients have had food in their stomachs on the day of procedures, causing delays. In one case last year, a 31-year-old diabetic patient was found to have a large quantity of food in the stomach; endoscopy procedures could not be performed, and a repeat attempt was scheduled after 36 hours on an empty stomach.
In another case, a 48-year-old woman who’d been on semaglutide for five months but had stopped the drug two days before still had 200 cc of food in her stomach. A 42-year-old man who’d been on semaglutide for two weeks and then off for two weeks, and had eaten nothing by mouth for 18 hours, still aspirated while an endoscopy was being performed.
A study last year assessed the residual gastric content (RGC) in patients after 12 hours of fasting before an elective procedure. Eight of the 27 patients who’d taken semaglutide in the previous 30 days, or 29%, had increased RGC—defined as any solid content or more than 0.8 mL/kg of fluid content—compared to 6.6% of those who hadn’t taken semaglutide (J Clin Anesth. 2023 doi:10.1016/j.jclinane.2023.111091) Another study found RGC in nine of 10 semaglutide users, but in just one of 10 non-users (Can J Anaesth. 2023. doi:10.1007/s12630-023-02549-5).
American Society of Anesthesiologists (ASA) guidelines suggest that those on weekly semaglutide should hold the medication for a week prior to a procedure or surgery, and those on a daily version, such as liraglutide, should hold it for the day of the procedure. The guidelines suggest that if a GLP-1 agonist prescribed for diabetes management is held for longer than the dosing schedule calls for, an endocrinologist should be consulted about anti-diabetic bridging therapy.
On the day of a procedure or surgery, if a patient has severe nausea or vomiting, the physician should consider delaying the procedure. If a patient has no gastrointestinal symptoms, but the drug was not held as advised, the procedure should go forward with “full stomach” precautions, or the gastric food volume should be evaluated by ultrasound, Dr. Younis said.
“Unfortunately, there’s no evidence to suggest what the optimal duration for fasting is for these patients,” he said. “And, therefore, we need to be on watch, be aware of it. We need to ask patients if they’re taking it or not and try to go with the guidelines.” Otherwise, he said, “We might end up with some serious complications.”
Sleep Apnea Benefits
On another front, there’s reason to wonder whether GLP-1 agonists and tirzepatide might be helpful for obstructive sleep apnea (OSA), said Dr. Younis. Obesity is a contributing factor to OSA and a frequent OSA comorbidity. But, he added, “It’s not really well defined how it really relates to losing weight.”
The standard therapy for obesity has been bariatric surgery, which has been found to show significant improvement in OSA in just 55% of cases, with many patients having no change.
“In reality, there are lot of people who don’t benefit, and bariatric surgery isn’t a cure,” Dr. Younis said. “Is this pharmacological therapy going to do better or not? We really don’t know.”
Two double-blinded, randomized, controlled trials showed that GLP-1 agonists improved apnea-hypopnea index scores in non-diabetic OSA patients (Int J Obes (Lond). 2016. doi:10.1038/ijo.2016.52). A new randomized, controlled trial evaluating tirzepatide for OSA benefits is currently underway.
The emergence of the weight loss drugs raises an array of questions, said Dr. Younis. If they come to be used in adolescence, might this mean the dawn of a generation of healthier adults less stricken with obesity and OSA? Will bariatric surgery become obsolete, with pharmacological therapy making it unnecessary?
It’s all unknown, said Dr. Younis, but, overall, physicians must keep in mind that the welfare of the patient is the top priority.
“We have great medications,” he said. “They might have side effects we need to be aware of. [These drugs have had] a lot of popularity and have been used off label. We need to make sure that we’re taking care of the patient,” he said. “Patients who stop can have a rebound weight problem, and we don’t know the long-term side effects. The [health] cost might be enormous.”
Thomas R. Collins is a freelance medical writer based in Florida.