According to the 2026 American Diabetes Association (ADA) Diabetes Care in the Hospital guidelines, glucagon-like peptide 1 receptor agonists (GLP-1 RAs) and dual glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 receptor agonists can delay gastric emptying and increase the risk of nausea and vomiting, which may raise the risk of pulmonary aspiration during procedures requiring general anesthesia or deep sedation. The Food and Drug Administration (FDA) has added warnings about this risk, but there is limited evidence on how to mitigate it, and the optimal duration for withholding these medications before surgery is unknown. Withholding once-weekly agents for one week is likely insufficient, and retrospective studies have shown that even holding semaglutide for up to 30 days may still result in increased residual gastric content. While the risk of aspiration pneumonia is uncertain, earlier guidance from the American Society of Anesthesiologists recommended holding daily GLP-1 RAs on the day of surgery and once-weekly agents at least seven days prior. More recent expert guidance advocates a personalized approach, allowing low-risk patients undergoing elective surgery to continue their GLP-1 RA and using a 24-hour liquid nutrition protocol or other measures for those at higher risk of gastrointestinal side effects. Perioperative management should consider the medication’s indication, current glycemic control, dose, duration, gastrointestinal symptoms, type and urgency of surgery, and type of anesthesia. Preoperative gastric ultrasound may be used to assess gastric contents, and full-stomach precautions may be implemented for patients with symptoms of delayed gastric emptying. If the medication is held and hyperglycemia is expected, alternative glycemic management, such as insulin, should be provided. [1]
A 2025 multi-society clinical practice guidance provided recommendations on the perioperative management of GLP-1RAs in patients undergoing surgical or endoscopic procedures. The document, developed collaboratively by the American Gastroenterological Association, American Society for Metabolic and Bariatric Surgery, American Society of Anesthesiologists, International Society of Perioperative Care of Patients with Obesity, and the Society of American Gastrointestinal and Endoscopic Surgeons, outlined concerns regarding delayed gastric emptying associated with GLP-1RAs. The guidance emphasized the risk of pulmonary aspiration due to residual gastric contents despite traditional fasting and addressed the gastrointestinal (GI) side effects that could complicate perioperative care. The recommendations were structured to support shared decision-making among procedural, anesthesia, and prescribing care teams while considering individual patient risk factors. According to the 2025 consensus guidance, patients without a significant risk of aspiration may continue GLP-1RA therapy perioperatively, while those at elevated risk (e.g., escalation phase, higher dose, weekly dosing, presence of GI symptoms, underlying conditions that may exacerbate delayed gastric emptying) should be assessed for potential discontinuation based on multidisciplinary discussion. If therapy is withheld, the recommended discontinuation timeline follows prior American Society of Anesthesiologists guidance, with daily GLP-1 formulations withheld on the day of surgery and weekly formulations discontinued one week prior. Additional safety measures include preoperative liquid diet modifications for at least 24 hours before the procedure, point-of-care gastric ultrasound when indicated, and consideration of rapid sequence induction for airway protection when retained gastric contents are suspected. The multi-society guidance underscored the need to balance aspiration risk with the metabolic benefits of GLP-1RAs, advocating for individualized patient management strategies while avoiding bias in treating obesity and related conditions. [2], [3]
A 2023 expert consensus discusses the potential risks associated with perioperative usage of GLP-1 RAs and provides insights on clinical considerations. The authors recommend discontinuing GLP-1 RAs at least three half-lives (approximately 88% clearance of the drug) before planned procedures. It is also suggested that clinicians may consider substituting with a shorter-acting GLP-1 receptor agonist as bridging therapy; however, the bridging therapy should also be discontinued at least three half-lives preoperatively. The authors note that these considerations do not constitute clinical practice guidelines due to insufficient evidence supporting them. [4]