ACE 21A Sample Question

A 23-year-old woman taking escitalopram, tirzepatide, and spironolactone presents for an esophagogastroduodenoscopy (EGD). Although she has been nil per os (NPO) for 8 hours, upon placement of the endoscope, her stomach is noted to be full of undigested food. Which of the following medications is MOST likely responsible?

A. Escitalopram X

B. Tirzepatide ✔

C. Spironolactone X

Read the discussion below.

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Discussion

Tirzepatide (sold under the trade names Mounjaro and Zepbound) is a glucagon-like peptide 1 (GLP-1) agonist used in the management of type 2 diabetes. Along with semaglutide, tirzepatide is also being used with increasing frequency for weight management, not only in patients with type 2 diabetes but also in those with obesity. Tirzepatide affects glucose control via several mechanisms, including improved glucose-dependent insulin secretion. However, it also increases gastric emptying times, promoting early satiety and contributing to weight loss. This slowed gastric emptying poses a risk for aspiration even in the setting of appropriate nil per os (NPO) status.

Escitalopram is a selective serotonin reuptake inhibitor used to treat depression and anxiety. While it may cause nausea, the use of escitalopram does not decrease gastric emptying.

Spironolactone is a potassium-sparing diuretic that may be used to treat heart failure and hypertension. It is also being used increasingly to treat acne. While it may cause nausea, the use of spironolactone does not decrease gastric emptying.

REFERENCES

1. Gropper MA, Cohen NH, Eriksson LI, Fleisher LA, Leslie K, Wiener-Kronish JP, eds. Miller’s Anesthesia. 9th ed. Elsevier; 2020: 955.
2. Wang W, Liu H, Xiao S, Liu S, Li X, Yu P. Effects of insulin plus glucagon-like peptide-1 receptor agonists (GLP-1RAs) in treating type 1 diabetes mellitus: a systematic review and meta-analysis. Diabetes Ther. 2017;8(4):727-738. doi:10.1007/s13300-017-0282-3
3. Klein SR, Hobai IA. Semaglutide, delayed gastric emptying, and intraoperative pulmonary aspiration: a case report. Can J Anaesth. 2023;70(8):1394-1396. doi:10.1007/s12630-023-02440-3
4. Joshi GP, Abdelmalak BB, Weigel WA, et al; American Society of Anesthesiologists Task Force on Preoperative Fasting. American Society of Anesthesiologists consensus-based guidance on preoperative management of patients (adults and children) on glucagon-like peptide-1 (GLP-1) receptor agonists. American Society of Anesthesiologists website. Published June 29, 2023. Accessed February 29, 2024. https://www.asahq.org/about-asa/newsroom/news-releases/2023/06/american-society-of-anesthesiologists-consensus-based-guidance-on-preoperative
5. Das DK, Shafer S. Gain changers: new generation of weight loss medications. ASA Monitor. 2023;87(9):1-4. https://pubs.asahq.org/monitor/article/87/9/1/138580/Gain-Changers-New-Generation-of-Weight-Loss

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