How long should Glucagon-like peptide-1 (GLP-1) receptor agonists be stopped prior to surgery?

GLP-1 Receptor Agonists Should Be Stopped for at Least Three Half-Lives Prior to Surgery

GLP-1 receptor agonists should be stopped for at least three half-lives before surgery to minimize aspiration risk, which corresponds to approximately 3 weeks for long-acting agents like semaglutide and 3-5 days for short-acting agents like liraglutide. 1, 2

Timing of Discontinuation Based on GLP-1 RA Type

The recommended discontinuation period varies by agent due to differences in half-lives:

• Long-acting GLP-1 RAs (e.g., semaglutide): Stop 3 weeks before surgery
• Short-acting GLP-1 RAs (e.g., liraglutide): Stop 3-5 days before surgery

This timing allows for clearance of approximately 88% of the drug from the body, which is necessary to reduce the risk of delayed gastric emptying and potential pulmonary aspiration during surgery. 1, 2

Different Recommendations Based on Indication

For Weight Loss Patients

• Hold GLP-1 RA for at least three half-lives prior to surgery 1
• No bridging therapy typically needed

For Type 2 Diabetes Patients

• Consult with the treating endocrinologist regarding:
  • Risks and benefits of holding the drug for at least three half-lives
  • Recommendations for bridging diabetic therapy if the GLP-1 RA will be held longer than the next scheduled dosing time 1
• Some evidence suggests continuing GLP-1 RAs during the perioperative period to maintain glycemic control 3, but the most recent guidelines prioritize aspiration risk reduction 1

Risk Mitigation Strategies When Unable to Stop GLP-1 RA

If the GLP-1 RA cannot be stopped for the recommended period, consider the following risk reduction strategies:

• Postponement and rescheduling of the procedure if possible
• 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
• Pre-emptive gastric decompression in very high-risk patients 1

High-Risk Patient Considerations

Pay special attention to patients who:

• Have recently started GLP-1 RA therapy or increased their dose
• Are experiencing nausea, vomiting, or abdominal distention
• Are taking other medications that delay gastric emptying (e.g., opioids)
• Have had previous gastro-esophageal surgery 1, 2

Documentation and Communication

Ensure proper documentation of:

• GLP-1 RA indication and dose
• Date drug commenced, dose variations, last dose taken
• Presence of gastrointestinal symptoms
• Co-prescribed drugs that can delay gastric emptying 1

Important Caveats

• Despite widespread use of GLP-1 RAs, high-quality studies on perioperative aspiration risk are limited
• The American Society of Anesthesiologists recommends withholding daily-dose GLP-1 therapy on the day of elective surgery and weekly-dose therapy for the week prior 4
• There is ongoing debate about the optimal approach, with some suggesting that the benefits of continuing GLP-1 RAs may outweigh risks in diabetic patients 3, 5
• The most recent guidelines from 2024 recommend the three half-lives approach as the safest option based on current evidence 1, 2

The decision to stop GLP-1 RAs should involve shared decision-making with patients, discussing the risks and benefits of each option before the procedure. 1