How soon before gastric bypass surgery should Zepbound (tirzepatide) be initiated?

Timing of Zepbound (Tirzepatide) Discontinuation Before Gastric Bypass Surgery

Zepbound (tirzepatide) should be discontinued at least 3-5 days before gastric bypass surgery to minimize the risk of aspiration during anesthesia induction.

Rationale for Discontinuation

GLP-1 receptor agonists like tirzepatide significantly delay gastric emptying, which increases the risk of pulmonary aspiration during anesthesia. This recommendation is based on several key considerations:

• The American Society of Anesthesiologists recommends stopping GLP-1 receptor agonists for at least three half-lives before surgery 1
• For daily-dosed GLP-1 RAs, discontinuation should occur 3-5 days before surgery 1
• For weekly-dosed medications like tirzepatide, discontinuation should ideally occur >1 week before elective surgery 2

Perioperative Management Protocol

Before Surgery

1. Discontinuation timing:

   • Stop tirzepatide at least 3-5 days before gastric bypass surgery
   • For higher-risk patients, consider stopping 1 week before surgery

2. Documentation requirements:

   • Document tirzepatide indication and dose
   • Record date medication was started
   • Note the last dose taken
   • Document any existing gastrointestinal symptoms
   • List any co-prescribed medications that might delay gastric emptying 1

3. Glucose management during discontinuation:

   • For diabetic patients, consult endocrinology for alternative glucose management during the tirzepatide pause
   • Monitor glucose levels closely during the perioperative period 1

Day of Surgery

1. Risk reduction strategies:
   • Consider prokinetic agents (e.g., metoclopramide) preoperatively
   • Use point-of-care gastric ultrasound to assess residual gastric contents
   • Employ rapid sequence intubation technique if indicated 1
   • Inform the anesthesiologist about tirzepatide use and the timing of the last dose

Special Considerations

Benefits of Preoperative Weight Loss

Preoperative weight loss before bariatric surgery has been associated with:

• Reduced surgical complications 3
• Better long-term weight loss outcomes 4
• Reduced liver mass, which facilitates the surgical procedure

Resuming Tirzepatide After Surgery

• Resume tirzepatide only after adequate oral intake has been established
• Follow standard dose titration protocols to minimize gastrointestinal side effects
• Start with the lowest dose and titrate up gradually 1

Potential Pitfalls and Caveats

1. Aspiration risk: Failure to discontinue tirzepatide before surgery significantly increases the risk of pulmonary aspiration during anesthesia induction.

2. Metabolic considerations: For patients with diabetes, abrupt discontinuation of tirzepatide may lead to hyperglycemia. Alternative glucose management strategies should be implemented during the perioperative period.

3. Nutritional monitoring: Patients who have lost significant weight on tirzepatide should be screened for malnutrition before surgery 2.

4. Postoperative management: After gastric bypass surgery, patients may require different dosing of tirzepatide or alternative weight management strategies.

By following these guidelines, the risk of aspiration during anesthesia can be minimized while still allowing patients to benefit from the weight loss effects of tirzepatide in preparation for bariatric surgery.