GLP-1 Receptor Agonists Withholding Before Surgery
GLP-1 receptor agonists should be withheld for at least three half-lives before surgery to reduce the risk of pulmonary aspiration due to delayed gastric emptying. 1
Rationale and Recommendations
The primary concern with GLP-1 receptor agonists in the perioperative period is their effect on delaying gastric emptying, which increases the risk of regurgitation and pulmonary aspiration during anesthesia induction.
Specific Recommendations Based on Indication
For patients taking GLP-1 RAs for weight loss:
- Hold for at least three half-lives before surgery 1
- This allows for clearance of approximately 88% of the drug
For patients taking GLP-1 RAs for diabetes:
Half-Lives of Common GLP-1 RAs
| Medication | Half-life | Withholding Period (3 half-lives) |
|---|---|---|
| Semaglutide | ~1 week | ~3 weeks |
| Dulaglutide | ~5 days | ~15 days |
| Liraglutide | ~13 hours | ~39 hours |
| Exenatide | ~2.4 hours | ~7.2 hours |
Risk Assessment and Mitigation
For patients who cannot withhold GLP-1 RAs for the recommended period, consider these aspiration risk reduction strategies 1:
- Postponement and rescheduling of elective procedures
- Clear fluid diet for some period before pre-operative fasting
- Prokinetic drugs such as metoclopramide or erythromycin pre-operatively
- Point-of-care gastric ultrasound to assess residual gastric contents
- Rapid-sequence intubation to reduce aspiration risk
- In very high-risk patients, pre-emptive gastric decompression
Special Considerations
High-Risk Patients
Consider additional precautions for patients who are:
- Unable to hold GLP-1 RAs for three half-lives
- Recently started on GLP-1 RAs or had dose increases
- Experiencing nausea, vomiting, or abdominal distention 1
Emerging Evidence
Recent research suggests that GLP-1 RA users may not have increased perioperative complications compared to non-users 2. However, case reports of regurgitation despite proper fasting highlight the potential risks 3. Until more definitive evidence emerges, the precautionary approach of withholding for three half-lives is recommended.
Diabetes Management During GLP-1 RA Withholding
For patients with diabetes who need to withhold GLP-1 RAs:
- Monitor blood glucose at least every 2-4 hours while NPO 1
- Consider basal-bolus insulin regimens, which have been associated with improved glycemic outcomes compared to correction-only insulin 1
- Target perioperative blood glucose of 100-180 mg/dL (5.6-10.0 mmol/L) 1
Documentation and Shared Decision-Making
Before surgery, document:
- Indication and dose of GLP-1 receptor agonist
- Date drug commenced, dose variations, last dose taken
- Symptoms of nausea, vomiting, or abdominal distention
- Co-prescribed drugs that can delay gastric emptying 1
Use a shared decision-making approach with patients to discuss risks and benefits of each management option 1.
Remember that while withholding GLP-1 RAs is recommended, the evidence is still evolving, and decisions should balance aspiration risk against the benefits of continued therapy, particularly for diabetes management.