When should the last Glucagon-like peptide-1 (GLP-1) dose be given in advance of surgery?

GLP-1 Receptor Agonist Management Before Surgery

GLP-1 receptor agonists should be held for at least three half-lives before surgery, with specific timing based on the indication for use (weight loss vs diabetes). 1

Timing Recommendations Based on Indication

For Weight Loss Patients

• Hold GLP-1 receptor agonists for at least three half-lives before surgery 1
• For example, semaglutide (Ozempic/Wegovy) would need to be held for approximately 3 weeks due to its long half-life 1

For Type 2 Diabetes Patients

• Consult with the treating endocrinologist regarding:
  • Risks and benefits of holding the drug for at least three half-lives 1
  • Need for bridging diabetic therapy during the period when GLP-1 receptor agonist is held 1
• Benefits of continuing GLP-1 receptor agonists closer to surgery include:
  • Better perioperative glycemic control
  • Potential decrease in postoperative major adverse cardiac events 1

Risk Assessment and Special Considerations

Higher Risk Patients Requiring Additional Precautions

• Recently started on GLP-1 receptor agonists or increased dose
• Experiencing nausea, vomiting, or abdominal distention
• Taking other medications that delay gastric emptying (opioids, proton pump inhibitors, tricyclic antidepressants)
• Recent intake of substances that delay gastric emptying (alcohol, cannabis)
• Previous gastro-esophageal surgery 1

Risk Mitigation Strategies

If unable to hold GLP-1 receptor agonist for three half-lives or in high-risk patients:

• Consider prokinetic drugs (metoclopramide or erythromycin) pre-operatively
• Use point-of-care gastric ultrasound to assess residual gastric contents
• Consider rapid sequence intubation to reduce aspiration risk
• In very high-risk patients, consider pre-emptive gastric decompression 1

Practical Approach for Day of Surgery

If GLP-1 Receptor Agonist Was Held for Three Half-Lives

• Proceed with standard pre-operative protocols
• Maintain target blood glucose range of 100-180 mg/dL (5.6-10.0 mmol/L) 1

If GLP-1 Receptor Agonist Was Not Held for Three Half-Lives

• Consider prokinetic drugs
• Perform gastric ultrasonography
• If gastric volume >1.5 ml/kg or solid matter present, consider delaying procedure
• If proceeding, use rapid sequence intubation 1

Postoperative Considerations

• Monitor blood glucose every 2-4 hours while NPO
• Use short or rapid-acting insulin as needed for glycemic control 1
• Resume GLP-1 receptor agonist therapy once patient is eating normally and metabolically stable

Common Pitfalls to Avoid

• Discontinuing long-acting GLP-1 receptor agonists for only 7 days may not be sufficient to ensure an empty stomach pre-operatively 1
• Attempting overly tight glycemic control (<80-100 mg/dL) perioperatively increases hypoglycemia risk without improving outcomes 1
• Failing to distinguish between patients taking GLP-1 receptor agonists for diabetes versus weight loss when making management decisions 1

While the American Society of Anesthesiologists recommends withholding daily-dose GLP-1 therapy on the day of surgery and weekly-dose therapy for the week prior 2, more recent evidence suggests this may be insufficient, particularly for long-acting agents. The current best practice is to hold these medications for at least three half-lives to clear approximately 88% of the drug 1.