Preoperative optimization of obese spine patients with GLP-1 receptor agonists: enhancing surgery and improving outcomes
Review Article

Preoperative optimization of obese spine patients with GLP-1 receptor agonists: enhancing surgery and improving outcomes

David Barkyoumb ORCID logo, Fauziyya Muhammad ORCID logo, Zachary A. Smith ORCID logo, Hakeem J. Shakir ORCID logo

Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA

Contributions: (I) Conception and design: All authors; (II) Administrative support: ZA Smith, HJ Shakir; (III) Provision of study materials or patients: D Barkyoumb, F Muhammad; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Hakeem J. Shakir, MD. Department of Neurosurgery, University of Oklahoma Health Sciences Center, 1000 N Lincoln Blvd. Suite 4000, Oklahoma City, OK 73104, USA. Email: hakeem-shakir@ouhsc.edu.

Abstract: In this paper, we propose a novel pharmaceutical approach to preoperative medical optimization for spinal surgery: glucagon-like peptide-1 receptor agonists (GLP-1 RAs). The adverse effects of obesity on spinal surgery outcomes are well-documented, with obese patients facing increased rates of surgical site infections, venous thromboembolism, revision, and mortality. Despite this robust body of evidence, current preoperative weight loss strategies are limited, as bariatric surgery represents the most effective, yet invasive, option. However, GLP-1 RAs offer a promising solution. These medications have repeatedly demonstrated remarkable efficacy in creating weight loss rivaling bariatric surgery. Furthermore, their convenience, dependability, and ability to control glucose, on top of evidence suggesting their potentially osteogenic, lean mass-preserving and cardioprotective properties, make GLP-1 RAs a strong, multi-dimensional solution. Although several studies have emerged examining the effect of these agents on perioperative outcomes in spinal surgery, there have yet to be any published investigations analyzing the utility of GLP-1 RAs as a weight-targeted tool for medical optimization specifically in spinal surgery. In this paper, we outline the significance of obesity’s adverse influence on spinal surgery outcomes, highlight the gap in available weight loss interventions, and elucidate the osteogenic and lean mass-preserving benefits of GLP-1 RAs. In doing so, we have identified GLP-1 RAs as an exceptional tool for mitigating obesity-related complications in spinal surgery. Further focused investigation has the potential to significantly improve surgical outcomes for this population of patients.

Keywords: Obesity; spinal surgery; glucagon-like peptide-1 receptor agonists (GLP-1 RAs); weight loss; medical optimization

Submitted Nov 18, 2024. Accepted for publication Feb 14, 2025. Published online Apr 14, 2025.

doi: 10.21037/jss-24-152

Introduction

Obesity is defined as a body mass index (BMI) greater than 30 kg/m2. It is estimated that one in eight people are now considered obese, with the number of obese adults more than doubling since 1990 (1). This pandemic of obesity brings with it a host of negative health outcomes, and extensive data demonstrates its contribution to numerous pathologies including cardiovascular disease, atherosclerosis, diabetes, and musculoskeletal dysfunction (2). Furthermore, obese individuals face a 23% and 44% increased burden of heart disease and diabetes, respectively, both of which are independent risk factors for adverse postoperative events (3).

Obesity directly impacts spinal health, contributing to low back pain, sciatica, degenerative disc disease, and disc herniation (4). Multiple mechanisms including chronic states of inflammation, ischemia-related structural changes, and alterations in loading mechanics contribute to this phenomenon (5). Additional evidence has shown that it can contribute to stenosis of the spinal canal, known as spinal epidural lipomatosis (SEL), which involves epidural accumulation of adipose tissue leading to thecal compression and subsequent manifestations of stenosis (6). Obesity also poses a technical challenge to spinal surgery. In addition to intubation and positioning difficulties, excess adipose tissue complicates pre- and intraoperative imaging. Procedures are further complicated by a lack of adequate exposure, leading to poor visualization and suboptimal utilization of surgical instruments.

Given the strong body of evidence substantiating the detrimental, multifaceted ramifications of obesity on spinal surgery, we propose a short-term pharmaceutical approach to preoperative weight loss using glucagon-like peptide-1 receptor agonists (GLP-1 RAs). These drugs have already proven to be extremely efficacious in inducing weight loss (7). Furthermore, evidence has demonstrated their osteoprotective properties, with research showing preservation of lumbar spine bone mineral density (BMD) during periods of weight loss (8). Taken together, these characteristics provide distinct advantages for spinal surgery and have the potential to make GLP-1 RAs a powerful, widely applicable solution for weight-related surgical risk mitigation.

Obesity and perioperative complications in spinal surgery

There exists a vast quantity of evidence substantiating the relationship between obesity and perioperative complications in spinal surgery. In a 2014 meta-analysis, Jiang et al. found that obesity was associated with significantly higher risks of surgical site infection [odds ratio (OR), 2.33], venous thromboembolism (OR, 3.15), mortality (OR, 2.6), revision rate (OR, 1.43), operating time (OR, 14.55), and blood loss [mean difference (MD), 28.89] (9). A subsequent meta-analysis from Goyal et al. in 2019 further supported these findings (10). While their meta-analysis did not find a significant difference in dural tears between obese and non-obese patients, other evidence points to the fact that unintentional durotomies are a complication for which obesity potentially increases the risk (11).

Current management strategies

Despite the abundance of evidence linking obesity and perioperative complications in spinal surgery, there is surprisingly little published data attempting to identify the optimal preoperative weight loss regimen. Current techniques largely focus on lifestyle modifications through instructional motivation, physical activities, and dietary changes. Specifically regarding dietary changes, low-calorie or very low-calorie diets can be efficacious in helping individuals achieve preoperative weight loss (12,13). However, in our experience these methods often fall short of producing adequate weight loss for our patients, especially considering that many of the patients scheduled for surgery are limited by the pathologies for which they are undergoing surgery.

One potential solution is bariatric surgery, which has a long-standing track record of producing safe and successful weight-loss in severely obese patients (14). Its growing popularity as a preoperative weight loss solution for spinal surgery patients is supported by evidence demonstrating its ability to mitigate postoperative complications (15). However, it is not without its own inherent drawbacks. A significant proportion of patients—over 15% according to a recent survey—experience regret following bariatric surgery, representing hesitancy among patients to undergo an additional surgery (16). Moreover, evidence suggests that gastric bypass may counterintuitively exacerbate spinal disorders (17). Taken together, these concerns underscore the urgent need for a superior weight-loss protocol—this is where GLP-1 RAs come into play.

Role of GLP-1 RAs in preoperative weight loss

GLP-1 RAs are a commonly used class of anti-diabetic agents that have become ubiquitous within popular culture due to their extremely effective weight loss properties. These agents, which primarily act by stimulating insulin secretion from pancreatic beta cells in a glucose-dependent manner while simultaneously suppressing glucagon release from alpha cells, regulate post-prandial glucose levels and improve insulin sensitivity (7). Weight loss is promoted via their activity on hypothalamic receptors which promote satiety and appetite regulation (7).

Originally developed for glycemic control in diabetic patients, GLP-1 RAs are now also approved by the Food and Drug Administration (FDA) for weight loss in obese or overweight adults with comorbidities, and for good reason. There is an extremely strong body of evidence supporting the efficacy of this drug class for weight loss (7). When considering the additional evidence suggesting their potentially cardioprotective and neuroprotective qualities, it is increasingly evident that these multifaceted agents can be predictable, reliable preoperative weight loss agents for spinal surgery patients (18).

Previous discussion in this paper highlighted the fact that, besides bariatric surgery, the landscape of preoperative weight management for spinal surgery patients is devoid of substantial evidence-based protocols. Although the field of bariatric surgery has explored the role of GLP-1 RAs in post-operative weight loss maintenance, there is a paucity of research across all surgical disciplines investigating these agents’ potential as a preoperative risk mitigation tool (19). Indeed, we believe that the utility of GLP-1 RAs specifically in this regard has been overlooked. A 2022 meta-analysis recently found that GLP-1 RAs demonstrated rates of weight loss equating to 15–20%: rates previously only seen with bariatric surgery (14). However, as opposed to bariatric surgery, GLP-1 RA administration is significantly more convenient than undergoing an additional procedure and does not require that the patient make any major changes to their food composition or meal timing. Adding to the list of benefits, GLP-1 RAs have also demonstrated osteogenic and bone-preserving properties with promising therapeutic potential (20).

In addition to optimizing the outcomes of spinal surgery, GLP-1 RAs also offer the potential to combat underlying spinal pathologies themselves. As previously discussed, SEL—which is characterized by the excessive deposition of adipose tissue in the epidural space—is a prime example. Whether it be laminectomy for spinal decompression or bariatric surgery to indirectly address the accumulation of adipose tissue, cases of SEL often necessitate surgical intervention to relieve the clinical manifestations of stenosis (6). Given the strong association between SEL and obesity (21), GLP-1 RAs may offer a novel therapeutic approach by targeting weight loss and potentially reducing epidural fat deposition. While direct evidence on the effects of GLP-1 RAs on SEL is lacking, their demonstrated efficacy in inducing significant weight loss suggests they could serve as an alternative to laminectomy or bariatric surgery, thereby obviating the need for an invasive procedure.

Special considerations

Although much of this paper has been devoted to the proposal of GLP-1 RAs as a preoperative weight management tool for spinal surgery, it is also important to address the considerations one must make when determining a patient’s eligibility for these agents. Of utmost importance is determining any absolute contraindications to GLP-1 RAs, which include history of pancreatitis, personal or family history of multiple endocrine neoplasia (MEN) 2A or 2B, or history of medullary thyroid cancer (7). Furthermore, common side effects of which patients should be aware include nausea, vomiting, diarrhea, and the potential for minor hypoglycemia (7).

While there is an absence of literature specifically outlining the optimal dosing regimen for preoperative weight loss with GLP-1 RAs, insights can be extrapolated from the previously established guidelines for general obesity management. A summary of these guidelines can be found in Table 1 (22-28). Currently there are three GLP-1 RAs FDA-approved for weight loss: liraglutide, semaglutide, and tirzepatide. Administration of these agents takes the form of either weekly (in the case of semaglutide and tirzepatide) or daily (liraglutide) subcutaneous injections. Although oral formulations of semaglutide are available, only the injectable form has been formally approved for the management of obesity. Each agent is typically started at a standard dose and can be up-titrated in a standardized fashion if needed, typically over the course of several weeks as specified in Table 1, until the maximum dose has been reached. Thereafter, patients can remain on this dose until the desired weight loss has been achieved. It is important to note that dosing regimens differ between obesity and diabetes management, with higher doses typically prescribed for weight loss. Consequently, diabetic patients requiring preoperative weight optimization may need an adjustment of their current GLP-1 RA dosage to achieve optimal results. The duration of preoperative therapy would likely be dependent upon both the amount of weight loss required and the time available before surgery, with evidence showing that weight loss can be expected within the first 4 to 8 weeks of initiating therapy (29). However, there is no evidence guiding the exact duration patients should be taking these agents in the preoperative period, and the weight loss threshold for which surgical outcomes are optimized has yet to be delineated. In these specific cases it is rational for the surgeon to refer these patients to either their primary care provider or endocrinologist for management of their GLP-1 RA regimen, as these specialists have a greater depth of knowledge and experience with these agents. In doing so, surgeons can promote a comprehensive, multidisciplinary approach to the optimization of their patient’s surgical outcomes. However, the lack of a standardized preoperative dosing regimen specifically for preoperative weight loss underscores the need for further investigations elucidating the optimal dosing strategy, treatment duration, and potential adaptations for the spinal surgery population.

Table 1

Summary of GLP-1 RA indications, routes of administration, and dosing

Drug Administration Dosing for weight loss Dosing for diabetes Maximum dose
Semaglutide—injection (Ozempic®, Wegovy®) Once weekly, subcutaneous injection Start: 0.25 mg/week. Increase dose every 4 weeks (0.5 mg, 1.0 mg, 1.7 mg) up to 2.4 mg/week Start: 0.25 mg/week for 4 weeks. Increase to 0.5 mg/week. May increase to 1 mg/week after 4 weeks, and again to 2mg/week after an additional 4 weeks Weight loss—2.4 mg/week; diabetes—2 mg/week
Tirzepatide (Mounjaro®, Zepbound®) Once weekly, subcutaneous injection Start: 2.5 mg/week. Increase to by 2.5 mg increments every 4 weeks as needed up to 15 mg/week Same as weight loss dosing 15 mg/week
Liraglutide (Victoza®, Saxenda®) Once daily, subcutaneous injection Start: 0.6 mg/day. Increase by 0.6 mg/day weekly up to 3.0 mg/day Start: 0.6 mg/day. Increase to 1.2 mg/day after 1 week. May increase to 1.8 mg/day after an additional week Weight loss—3.0 mg/day; diabetes—1.8 mg/day
Semaglutide—oral (Rybelsus®) Once daily, oral tablet Not FDA-approved for weight loss Start: 3 mg/day for 30 days. Increase to 7 mg/day. May increase to 14 mg/day after 30 days 14 mg/day
Dulaglutide (Trulicity®) Once weekly, subcutaneous injection Not FDA-approved for weight loss Start: 0.75 mg/week. Increase to 1.5 mg/week after 4 weeks. Can increase by 1.5 mg increments up to 4.5 mg/week 4.5 mg/week
Exenatide ER (Bydureon®) Once weekly, subcutaneous injection Not FDA-approved for weight loss 2 mg/week 2 mg/week
Exenatide (ByettaTM) Twice daily, subcutaneous injection Not FDA-approved for weight loss Start: 5 μg twice daily. Increase to 10 μg twice daily after 1 month 10 μg twice daily

ER, extended-release; FDA, Food and Drug Administration; GLP-1 RA, glucagon-like peptide-1 receptor agonist.

One critical surgery-specific consideration for GLP-1 RAs is the impact of delayed gastric emptying (DGE) on the risk of retained gastric contents (RGC) and subsequent intraoperative aspiration. Recent unified, multisociety guidelines (30) contain several recommendations, the first of which involves identifying variables that elevate a patient’s risk for DGE and aspiration. These include, among others, patients in the initial phases of GLP-1 RA therapy, those on higher doses, and those with pre-existing gastrointestinal symptoms such as nausea, vomiting, and constipation. In those without elevated risk of DGE and aspiration, GLP-1 RAs can be continued preoperatively. If risk factors are present, the decision of whether to discontinue GLP-1 RAs must be carefully weighed against the potential surgical and medical risks of triggering an adverse metabolic state such as hyperglycemia. In such cases, additional measures such as evaluation of gastric volume via ultrasound and alterations in preoperative diet composition can be utilized to optimize the safety of perioperative GLP-1 RA use. With this being said, these guidelines are based on expert interpretation of a limited number of case reports, and thus further highlight the need for research examining the perioperative effects of GLP-1 RAs.

Several other publications have highlighted the necessity for further investigation. A 2024 prospective cross-sectional trial found that, compared to those not on these agents, the prevalence of RGC was almost 2.5 times higher in patients on GLP-1 RAs in the preoperative period (31). Another case report describes a 42-year-old that aspirated gastric contents into the trachea and bronchi during surgery despite an 18-hour preoperative fasting period; this patient had been on semaglutide in the two months leading up to surgery (32).

Although this evidence, albeit limited, certainly raises valid concerns regarding the use of GLP-1 RAs in the preoperative period, endocrinologists have the opportunity to approach this topic from a multi-disciplinary perspective. In their recent commentary, Umpierrez et al. highlight that the 2023 American Society of Anesthesiologists (ASA) Task Force recommendations were based on limited data, and propose several key considerations for physicians prescribing GLP-1 RAs in the preoperative period (33). One such consideration is the relationship between therapy duration and DGE. Although DGE can certainly occur with GLP-1 RAs, this side effect follows a tachyphylactic timeline and is typically limited to the initial weeks of therapy (34). Additionally, the use of gastric ultrasound to guide anesthetic management in these patients warrants attention. Although the application of gastric ultrasound in assessing RGC is under investigation (35), further research is needed to develop a definitive protocol delineating a threshold of RGC that would necessitate alterations in anesthetic management or deferral of surgery.

Addressing emerging evidence and misconceptions

To our knowledge, there are currently no publications specifically analyzing the safety and efficacy of GLP-1 RAs as preoperative weight loss agents in spinal surgery. However, a recent study evaluating postoperative outcomes in diabetic patients undergoing cervical decompression and fusion offers valuable insights into the impact of preoperative GLP-1 RA use specifically on cervical spinal surgery. In their retrospective cohort study of type 2 diabetics on semaglutide within six months of surgery, Tao et al. found that there was no difference in surgical complications or readmission rates between patients on semaglutide and propensity score-matched controls not taking the agent (36). Of note, complications were measured using a composite complication score that incorporated surgical site infection, wound complications, and six-month reoperation rates. These findings, while not directly supporting or refuting the role of these agents for preoperative weight loss, suggest that GLP-1 RAs do not negatively affect postoperative outcomes in cervical spinal surgery.

Conversely, a recent publication from Khalid et al. describes how semaglutide exposure increases the risk for subsequent surgery following transforaminal lumbar interbody fusion (TLIF) (37). This study, which examined patients undergoing short-segment TLIF (defined as three levels or less), found that patients who had utilized semaglutide prior to surgery were more likely to undergo an additional surgery within one-year post-TLIF compared to those without semaglutide exposure. The authors suggested that GLP-1 RAs, whether it be via altered bone metabolism or loss of muscle tissue, have a potentially undesirable influence on postoperative spinal surgery outcomes.

At first glance, this study seems to challenge both the results demonstrated by Tao et al. (36) and our proposed benefits of GLP-1 RAs in the preoperative period. However, it is important to note that a causal mechanism for these results has yet to be elucidated. On the contrary, existing literature indicates that GLP-1 RAs may instead possess osteoprotective properties. For example, in their randomized controlled trial, Hygum et al. found that BMD of the lumbar spine was preserved in patients on liraglutide during a 26-week weight-loss period (8). Given the data establishing that weight loss typically results in a decreased BMD (38), one can infer that GLP-1 RAs might actually provide distinct advantages for spinal surgery patients, potentially making them more beneficial than the traditional regimens of diet and exercise alone. Proposed mechanisms for this effect include enhanced differentiation and reduction of apoptosis in osteoblasts, reduced differentiation of osteoclasts, and increases in trabecular and cortical bone mass (20).

Furthermore, despite speculation that GLP-1 RA-induced weight loss intensifies muscle wasting, evidence suggests that rates of lean tissue loss in patients are not significantly different compared to conventional weight loss methods. The standard proportion of body mass lost that consists of lean muscle tissue has been estimated to range between 15% and 40% (39,40). Several clinical trials analyzing weight loss in patients utilizing GLP-1 RAs have found this proportion to be of similar value, with values ranging between approximately 25% and 40% (41,42).

Irrespective of the evidence, we commend both groups of authors for their vision, expertise, and dedication in making formative contributions to a topic of investigation that is in its infancy. Their investigations, along with what has been discussed in this paper, underscore a critical conclusion—efforts must be directed towards validating the safety and efficacy of GLP-1 RAs as preoperative weight loss agents for spinal surgery patients.

Conclusions

By outlining the significance of obesity’s adverse influence on the outcomes of spinal surgery, highlighting the gap in available weight loss interventions, and elucidating the osteogenic and lean-mass-preserving benefits of GLP-1 RAs, we have identified GLP-1 RAs as an exceptional tool for mitigating obesity-induced surgical complications. For patients and surgeons to maximize the benefits of these agents, resources and academic efforts must be directed towards rigorous investigation of GLP-1 RAs specifically as pre-operative weight loss interventions for surgical risk-mitigation.

Acknowledgments

None.

Footnote

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-24-152/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-24-152/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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References

  1. Worldwide trends in underweight and obesity from 1990 to 2022: a pooled analysis of 3663 population-representative studies with 222 million children, adolescents, and adults. Lancet 2024;403:1027-50. [Crossref] [PubMed]
  2. Powell-Wiley TM, Poirier P, Burke LE, et al. Obesity and Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circulation 2021;143:e984-e1010. [Crossref] [PubMed]
  3. Leitner DR, Frühbeck G, Yumuk V, et al. Obesity and Type 2 Diabetes: Two Diseases with a Need for Combined Treatment Strategies - EASO Can Lead the Way. Obes Facts 2017;10:483-92. [Crossref] [PubMed]
  4. Shiri R, Karppinen J, Leino-Arjas P, et al. The association between obesity and low back pain: a meta-analysis. Am J Epidemiol 2010;171:135-54. [Crossref] [PubMed]
  5. Jackson KL 2nd, Devine JG. The Effects of Obesity on Spine Surgery: A Systematic Review of the Literature. Global Spine J 2016;6:394-400. [Crossref] [PubMed]
  6. Manjila S, Fana M, Medani K, et al. Spinal Epidural Lipomatosis Causing Lumbar Canal Stenosis: A Pictorial Essay on Radiological Grading and the Role of Bariatric Surgery Versus Laminectomy. Cureus 2022;14:e26492. [Crossref] [PubMed]
  7. Popoviciu MS, Păduraru L, Yahya G, et al. Emerging Role of GLP-1 Agonists in Obesity: A Comprehensive Review of Randomised Controlled Trials. Int J Mol Sci 2023;24:10449. [Crossref] [PubMed]
  8. Hygum K, Harsløf T, Jørgensen NR, et al. Bone resorption is unchanged by liraglutide in type 2 diabetes patients: A randomised controlled trial. Bone 2020;132:115197. [Crossref] [PubMed]
  9. Jiang J, Teng Y, Fan Z, et al. Does obesity affect the surgical outcome and complication rates of spinal surgery? A meta-analysis. Clin Orthop Relat Res 2014;472:968-75. [Crossref] [PubMed]
  10. Goyal A, Elminawy M, Kerezoudis P, et al. Impact of obesity on outcomes following lumbar spine surgery: A systematic review and meta-analysis. Clin Neurol Neurosurg 2019;177:27-36. [Crossref] [PubMed]
  11. Burks CA, Werner BC, Yang S, et al. Obesity is associated with an increased rate of incidental durotomy in lumbar spine surgery. Spine (Phila Pa 1976) 2015;40:500-4. [Crossref] [PubMed]
  12. Griffin SB, Ross LJ, Burstow MJ, et al. Efficacy of a dietitian-led very low calorie diet (VLCD) based model of care to facilitate weight loss for obese patients prior to elective, non-bariatric surgery. J Hum Nutr Diet 2021;34:188-98. [Crossref] [PubMed]
  13. Chowdhury N, Hasnan S, Ullah S, et al. Low-calorie diets are effective for weight loss in patients undergoing benign upper gastrointestinal surgery: a systematic review and meta-analysis. Surg Endosc 2024;38:4171-85. [Crossref] [PubMed]
  14. Sarma S, Palcu P. Weight loss between glucagon-like peptide-1 receptor agonists and bariatric surgery in adults with obesity: A systematic review and meta-analysis. Obesity (Silver Spring) 2022;30:2111-21. [Crossref] [PubMed]
  15. Gupta S, Tao X, Matur AV, et al. Bariatric Surgery Before Spine Surgery is Associated With Fewer Postsurgical Complications: A Systematic Review and Meta-Analysis. Spine (Phila Pa 1976) 2023;48:944-9. [PubMed]
  16. Dijkhorst PJ, Nijland LMG, van Veen RN, et al. Factors associated with decision regret after bariatric surgery. Clin Obes 2024;14:e12633. [Crossref] [PubMed]
  17. Passias PG, Horn SR, Ihejirika YU, et al. Bariatric Surgery Population at Significantly Increased Risk of Spinal Disorders and Surgical Intervention Compared With Morbidly Obese Patients. Clin Spine Surg 2020;33:E158-61. [Crossref] [PubMed]
  18. Sharma D, Verma S, Vaidya S, et al. Recent updates on GLP-1 agonists: Current advancements & challenges. Biomed Pharmacother 2018;108:952-62. [Crossref] [PubMed]
  19. Tang T, Abbott S, le Roux CW, et al. Preoperative weight loss with glucagon-like peptide-1 receptor agonist treatment predicts greater weight loss achieved by the combination of medical weight management and bariatric surgery in patients with type 2 diabetes: A longitudinal analysis. Diabetes Obes Metab 2018;20:745-8. [Crossref] [PubMed]
  20. Herrou J, Mabilleau G, Lecerf JM, et al. Narrative Review of Effects of Glucagon-Like Peptide-1 Receptor Agonists on Bone Health in People Living with Obesity. Calcif Tissue Int 2024;114:86-97. [Crossref] [PubMed]
  21. Kim K, Mendelis J, Cho W. Spinal Epidural Lipomatosis: A Review of Pathogenesis, Characteristics, Clinical Presentation, and Management. Global Spine J 2019;9:658-65. [Crossref] [PubMed]
  22. AstraZeneca Pharmaceuticals LP [Internet]. [cited 2025 Jan 17]. BYDUREON BCISE- exenatide injection, suspension, extended release. Package Insert. Available from: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=2d18cfc4-e0de-4814-a712-c1b7c504bff5
  23. AstraZeneca Pharmaceuticals LP [Internet]. [cited 2025 Jan 17]. BYETTA- exenatide injection. Package Insert. Available from: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=53d03c03-ebf7-418d-88a8-533eabd2ee4f
  24. Eli Lilly and Company [Internet]. [cited 2025 Jan 17]. MOUNJARO- tirzepatide injection, solution. Package Insert. Available from: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d2d7da5d-ad07-4228-955f-cf7e355c8cc0
  25. Novo Nordisk [Internet]. [cited 2025 Jan 17]. RYBELSUS- oral semaglutide tablet. Package Insert. Available from: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=27f15fac-7d98-4114-a2ec-92494a91da98
  26. Eli Lilly and Company [Internet]. [cited 2025 Jan 17]. TRULICITY- dulaglutide injection, solution. Package Insert. Available from: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=463050bd-2b1c-40f5-b3c3-0a04bb433309
  27. Novo Nordisk [Internet]. [cited 2025 Jan 17]. VICTOZA- liraglutide injection. Package Insert. Available from: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=5a9ef4ea-c76a-4d34-a604-27c5b505f5a4
  28. Novo Nordisk [Internet]. [cited 2025 Jan 17]. WEGOVY- semaglutide injection, solution. Package Insert. Available from: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ee06186f-2aa3-4990-a760-757579d8f77b
  29. Das SR, Everett BM, Birtcher KK, et al. 2020 Expert Consensus Decision Pathway on Novel Therapies for Cardiovascular Risk Reduction in Patients With Type 2 Diabetes: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2020;76:1117-45. [Crossref] [PubMed]
  30. Kindel TL, Wang AY, Wadhwa A, et al. Multisociety clinical practice guidance for the safe use of glucagon-like peptide-1 receptor agonists in the perioperative period. Surg Obes Relat Dis 2024;20:1183-6. [Crossref] [PubMed]
  31. Sen S, Potnuru PP, Hernandez N, et al. Glucagon-Like Peptide-1 Receptor Agonist Use and Residual Gastric Content Before Anesthesia. JAMA Surg 2024;159:660-7. [Crossref] [PubMed]
  32. Klein SR, Hobai IA. Semaglutide, delayed gastric emptying, and intraoperative pulmonary aspiration: a case report. Can J Anaesth 2023;70:1394-6. [Crossref] [PubMed]
  33. Umpierrez G, Pasquel FJ, Duggan E, et al. Should We Stop Glucagon-Like Peptide-1 Receptor Agonists Before Surgical or Endoscopic Procedures? Balancing Limited Evidence With Clinical Judgment. J Diabetes Sci Technol 2024; Epub ahead of print. [Crossref] [PubMed]
  34. Nauck MA, Kemmeries G, Holst JJ, et al. Rapid tachyphylaxis of the glucagon-like peptide 1-induced deceleration of gastric emptying in humans. Diabetes 2011;60:1561-5. [Crossref] [PubMed]
  35. Chang MG, Ripoll JG, Lopez E, et al. A Scoping Review of GLP-1 Receptor Agonists: Are They Associated with Increased Gastric Contents, Regurgitation, and Aspiration Events? J Clin Med 2024;13:6336. [Crossref] [PubMed]
  36. Tao X, Ranganathan S, Van Halm-Lutterodt N, et al. No Difference in Short-term Surgical Outcomes From Semaglutide Treatment for Type 2 Diabetes Mellitus After Cervical Decompression and Fusion: A Propensity Score-matched Analysis. Spine (Phila Pa 1976) 2025;50:515-21. [Crossref] [PubMed]
  37. Khalid SI, Massaad E, Thomson K, et al. Semaglutide exposure and its association with adverse outcomes in diabetic patients undergoing transforaminal lumbar interbody fusion for lumbar degenerative disc disease. J Neurosurg Spine 2025;42:1-8. [PubMed]
  38. Zibellini J, Seimon RV, Lee CM, et al. Does Diet-Induced Weight Loss Lead to Bone Loss in Overweight or Obese Adults? A Systematic Review and Meta-Analysis of Clinical Trials. J Bone Miner Res 2015;30:2168-78. [Crossref] [PubMed]
  39. Willoughby D, Hewlings S, Kalman D. Body Composition Changes in Weight Loss: Strategies and Supplementation for Maintaining Lean Body Mass, a Brief Review. Nutrients 2018;10:1876. [Crossref] [PubMed]
  40. Bosy-Westphal A, Kossel E, Goele K, et al. Contribution of individual organ mass loss to weight loss-associated decline in resting energy expenditure. Am J Clin Nutr 2009;90:993-1001. [Crossref] [PubMed]
  41. Jastreboff AM, Aronne LJ, Ahmad NN, et al. Tirzepatide Once Weekly for the Treatment of Obesity. N Engl J Med 2022;387:205-16. [Crossref] [PubMed]
  42. Wilding JPH, Batterham RL, Calanna S, et al. Once-Weekly Semaglutide in Adults with Overweight or Obesity. N Engl J Med 2021;384:989-1002. [Crossref] [PubMed]
Cite this article as: Barkyoumb D, Muhammad F, Smith ZA, Shakir HJ. Preoperative optimization of obese spine patients with GLP-1 receptor agonists: enhancing surgery and improving outcomes. J Spine Surg 2025;11(2):339-346. doi: 10.21037/jss-24-152

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