Is an 8-day holding period sufficient for semaglutide (glucagon-like peptide-1 receptor agonist) before surgery scheduled for 10/21, given the last dose was taken on 10/13?

Semaglutide Holding Period Before Surgery

An 8-day holding period for semaglutide before surgery scheduled on 10/21 is NOT sufficient, as current evidence recommends holding weekly GLP-1 receptor agonists for at least three half-lives (approximately 3 weeks for semaglutide) to reduce the risk of pulmonary aspiration.

Risk of Aspiration with Semaglutide

• Semaglutide significantly delays gastric emptying, which increases the risk of regurgitation and pulmonary aspiration during anesthesia, even with proper fasting 1
• Multiple case reports document regurgitation and pulmonary aspiration in patients taking semaglutide despite prolonged fasting periods (12-20 hours) 1
• A recent prospective observational study found that 40% of patients who received semaglutide within 10 days of surgery had increased residual gastric content compared to only 3% in the control group 2
• Even patients who stopped semaglutide 6-7 days before surgery experienced regurgitation of gastric contents during anesthesia 1

Recommended Holding Period

• Current guidelines recommend holding weekly GLP-1 receptor agonists like semaglutide for at least three half-lives (approximately 3 weeks for semaglutide) before elective surgery 1
• The American Society of Anesthesiologists recommends holding weekly GLP-1 receptor agonists for at least 1 week before elective surgery, but emerging evidence suggests this may be insufficient 1
• Semaglutide has an elimination half-life of approximately 1 week, meaning it remains in circulation for about 5 weeks after the last dose 3
• Discontinuation of semaglutide for only 7-10 days has been shown to be insufficient to normalize gastric emptying 1, 2

Risk Assessment and Management

• With only 8 days between the last dose (10/13) and surgery (10/21), the patient should be considered at high risk for retained gastric contents 1
• Risk reduction strategies should be implemented if surgery cannot be postponed 1:
  • Consider using prokinetic drugs such as metoclopramide pre-operatively 1
  • Perform point-of-care gastric ultrasound to assess residual gastric content 1, 2
  • Implement rapid sequence intubation to reduce aspiration risk 1
  • Consider the surgery as a "full stomach" case 1

Special Considerations

• The risk-benefit assessment differs based on the indication for semaglutide use:
  • For patients taking semaglutide for weight loss, the risks of continuing until shortly before surgery likely outweigh the benefits 1
  • For patients with diabetes, consultation with an endocrinologist is recommended to weigh the benefits of glycemic control against aspiration risk 1
• Multiple case reports document aspiration events in patients who held semaglutide for 4-7 days before surgery, suggesting that 8 days is still within the high-risk period 1

Conclusion

Based on the most recent evidence, an 8-day holding period for semaglutide before surgery on 10/21 is insufficient to minimize the risk of regurgitation and pulmonary aspiration. If possible, the surgery should be rescheduled to allow for at least three half-lives (approximately 3 weeks) after the last dose. If rescheduling is not possible, appropriate aspiration risk reduction strategies should be implemented.