What pre‑operative evaluation should a primary‑care physician perform for a 38‑year‑old man with a BMI of 30.44 who is taking exogenous testosterone and Wegovy (semaglutide) and has no other medical history before orthopedic surgery?

Pre-Operative Evaluation for a 38-Year-Old Man on Testosterone and Wegovy Before Orthopedic Surgery

For this 38-year-old man with BMI 30.44 taking exogenous testosterone and Wegovy (semaglutide), you must address three critical peri-operative concerns: aspiration risk from GLP-1 RA therapy, hematologic effects of testosterone, and thromboembolism risk related to obesity.

Medication Management

Wegovy (Semaglutide) - Aspiration Risk Assessment

Continue Wegovy through surgery but implement aspiration risk mitigation strategies 1. The 2025 UK multidisciplinary consensus statement recommends continuation of GLP-1 receptor agonists peri-operatively, supported by risk stratification and shared decision-making 1.

Key considerations for semaglutide:

• Delayed gastric emptying persists even with chronic use - while tachyphylaxis develops with continuous exposure, scintigraphy studies show delayed gastric emptying remains present with long-acting agents like semaglutide after 12-20 weeks 2
• Risk stratification required: Assess for symptoms of gastroparesis (early satiety, bloating, nausea), recent dose escalation, and type of anesthesia planned
• Communicate with anesthesia team about GLP-1 RA use for appropriate airway management planning 1
• Consider extended NPO times or rapid sequence induction based on anesthesia assessment 2

Exogenous Testosterone - Hematologic Monitoring

Check hematocrit before surgery 3. The 2010 Endocrine Society guideline specifies that baseline hematocrit above 50% is a relative contraindication to surgery because testosterone increases hemoglobin, particularly in men 3.

For testosterone therapy monitoring:

• Measure hematocrit at baseline - if >54%, surgery should be postponed until it decreases to safe levels 3
• Document testosterone formulation and dosing schedule
• Note: At age 38, this patient likely has functional/obesity-related hypogonadism rather than organic hypogonadism 4, 5
• Fertility consideration: Exogenous testosterone suppresses spermatogenesis and should not be prescribed to men interested in current or future fertility 4

Cardiovascular and Metabolic Assessment

Obesity-Related Risk Stratification (BMI 30.44 = Grade 1 Obesity)

Screen for obesity-related comorbidities that increase peri-operative cardiac risk 6. The 2009 AHA Science Advisory identifies specific conditions requiring evaluation:

Essential screening:

• Obstructive sleep apnea - high prevalence in obesity, increases pulmonary hypertension risk 6
• Systemic hypertension - measure blood pressure
• Cardiac arrhythmias (particularly atrial fibrillation) 6
• Functional capacity assessment - can he climb 2 flights of stairs or walk 4 blocks without symptoms? 7
• Deep vein thrombosis history - critical for VTE prophylaxis planning 6

Laboratory Evaluation

Obtain targeted laboratory testing based on medications and obesity 7:

Required tests:

• Hematocrit (for testosterone monitoring) 3
• Hemoglobin A1c - semaglutide is prescribed for weight loss but assess glycemic status 8
• Basic metabolic panel - assess renal function (relevant for both medications)
• TSH - semaglutide carries MTC risk; document baseline thyroid function 8, 9

Do NOT routinely check: The evidence does not support routine pancreatic enzymes (lipase/amylase) or calcitonin in asymptomatic patients despite theoretical concerns 9. These should only be obtained if clinically indicated.

Medication-Specific Screening

Wegovy Contraindications and Precautions

Screen for absolute contraindications 8:

• Personal or family history of medullary thyroid carcinoma (MTC)
• Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
• Known hypersensitivity to semaglutide

Assess disease history 9:

• Personal history of pancreatitis
• Thyroid abnormalities or thyroid cancer
• Retinopathy or significant eye problems
• Diabetic neuropathy (if diabetic)

Testosterone Therapy Verification

Confirm indication and monitoring compliance 3, 4:

• Document reason for testosterone use (likely obesity-related functional hypogonadism at age 38)
• Verify testosterone levels are in mid-normal range (not supraphysiologic)
• If patient desires fertility now or in future, testosterone should be discontinued and alternative management considered 4

Thromboembolism Prophylaxis Planning

Coordinate VTE prophylaxis with surgical team 10. The 2025 EASO bariatric surgery consensus (applicable to obese patients undergoing surgery) recommends:

• Pharmacological thromboprophylaxis beginning day prior to surgery or at induction 10
• Extended prophylaxis duration based on individual risk factors
• BMI 30.44 places patient at increased VTE risk 6

Pre-Operative Optimization Timeline

For elective orthopedic surgery, allow adequate time for optimization 11:

If abnormalities identified:

• Hematocrit >50%: Delay surgery, adjust testosterone, recheck in 3-6 months 3
• Uncontrolled hypertension or newly identified cardiac issues: Optimize before proceeding 7
• Symptomatic gastroparesis on semaglutide: Consider holding dose and reassessing 1

Documentation and Communication

Provide surgical team with specific information 7:

• Current medications with doses: testosterone formulation/frequency, Wegovy 2.4 mg weekly
• Hematocrit result
• Functional capacity assessment
• Sleep apnea screening result
• VTE risk factors
• Aspiration risk stratification for GLP-1 RA use

Common pitfall: Failing to communicate GLP-1 RA use to anesthesia team, leading to inadequate aspiration precautions 2, 1. This must be explicitly documented and discussed.

Shared decision-making: Discuss with patient the option to hold semaglutide for 1-2 weeks pre-operatively if high aspiration risk identified, though current consensus supports continuation with appropriate precautions 1.