SUMMARY

GLP-1 receptor agonists (GLP-1RAs) are widely used for type 2 diabetes, obesity, and heart failure. Their ability to delay gastric emptying raises perioperative risks, notably aspiration during anesthesia, even after standard fasting. Post-operative complications can mimic the nausea, abdominal pain, vomiting and constipation side effects from GLP-1RAs, making complications difficult to assess. Multi-society guidance recommends a risk-based, multidisciplinary approach to perioperative management.

Key Considerations

• GLP-1RAs slow gastric emptying, increasing aspiration risk during sedation or anesthesia.
• Symptoms e.g., nausea | vomiting | abdominal pain| constipation may overlap with perioperative complications
• Evidence-based perioperative guidelines are limited; clinical practice recommendations are consensus-driven

Risk Assessment:

These variables can increase the risk of delayed gastric emptying, aspiration. Assess risk factors well before surgery to allow for preoperative planning.

• Escalation phase: Higher risk of delayed gastric emptying than maintenance phase
• High dose: Greater GI side effects and risk
• Weekly dosing: More GI side effects than daily formulations
• Active GI symptoms: Nausea, vomiting, abdominal pain, dyspepsia, constipation
• Comorbid conditions e.g., Gastroparesis | bowel dysmotility | Parkinson’s disease

Perioperative Management

Shared Decision-Making

• Involve patient, proceduralist, anesthesiologist, and prescribing provider
• Weigh metabolic benefits of GLP-1RA vs. aspiration risk
• Avoid bias: Do not withhold solely for obesity indication

Holding GLP-1RA Therapy

• No elevated risk: Continue GLP-1RA
• Elevated risk: Consider withholding GLP-1RA
  • Daily formulations: Hold on day of surgery
  • Weekly formulations: Hold 1 week prior
• Bridging therapy: May be resource-intensive and not always feasible
• All patients: Assess for delayed gastric emptying symptoms on day of procedure

Aspiration Risk Reduction

• Preoperative diet modification: Consider 24-hour liquid diet for at-risk patients
• Gastric ultrasound: Use if concern for retained gastric contents (institution-dependent)
• Anesthesia planning: Consider rapid sequence induction for intubation if aspiration risk is high
• Shared decision-making: Discuss risks/benefits of proceeding vs. canceling procedure if retained gastric contents are present

Special Populations

• Obesity/overweight: Do not withhold GLP-1RA solely for these indications
• Other gastroparesis patients: Apply similar perioperative precautions.

Conclusion

• Perioperative GLP-1RA management should be individualized, emphasizing shared decision-making and risk assessment
• Recommendations may change as new therapies and evidence emerge
• Current guidance is based on expert consensus, not high-level evidence

Learn More-Primary Resources

Multisociety Clinical Practice Guidance for the Safe Use of Glucagon-like Peptide-1 Receptor Agonists in the Perioperative Period

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