Do you need to stop Glucagon-like peptide-1 (GLP-1) medications prior to surgery?

GLP-1 Medications Should Be Stopped Prior to Surgery

Yes, GLP-1 receptor agonists should be discontinued before elective surgery due to the risk of pulmonary aspiration from delayed gastric emptying, despite the lack of robust prospective data. The most recent multidisciplinary consensus from major UK societies in 2025 provides clear guidance on this critical safety issue 1.

Recommended Cessation Periods by Medication

The timing of discontinuation depends on the specific GLP-1 RA and its half-life. Hold these medications for at least three half-lives (achieving approximately 88% drug clearance) before procedures requiring sedation or general anesthesia 2:

• Semaglutide (Ozempic/Wegovy): Stop 3 weeks before surgery (7-day half-life) 2
• Dulaglutide (Trulicity): Stop 2 weeks before surgery (4.5-4.7 day half-life) 2
• Liraglutide (Victoza/Saxenda): Stop 39 hours before surgery (13-hour half-life) 2
• Exenatide (Byetta): Stop 7.2 hours before surgery (2.4-hour half-life) 2

Why This Matters: The Aspiration Risk

GLP-1 RAs significantly delay gastric emptying, which persists even after standard preoperative fasting 1. Multiple case reports document regurgitation and pulmonary aspiration during general anesthesia in patients taking these medications despite adherence to fasting guidelines 1, 2. The FDA drug labels for both liraglutide and dulaglutide now explicitly warn about pulmonary aspiration risk during general anesthesia or deep sedation, noting that "available data are insufficient to inform recommendations" but acknowledging the problem exists 3, 4.

Standard fasting guidelines are inadequate for patients on GLP-1 RAs 2. Endoscopic and ultrasound studies have demonstrated retained gastric solids and liquids in fasted patients taking these medications 1.

When You Cannot Wait Three Half-Lives

If surgery cannot be delayed (particularly for diabetes management rather than weight loss indication), implement these risk mitigation strategies 1, 2:

• Perform point-of-care gastric ultrasound to assess residual gastric contents before induction 1, 2
• Administer prokinetic drugs (metoclopramide or erythromycin) preoperatively 1, 2
• Use modified rapid sequence intubation with a cuffed endotracheal tube rather than supraglottic airway 1
• Position patient head-up for induction of anesthesia 1
• Consider gastric tube placement to empty stomach before induction and extubation 1
• Delay procedure if gastric volume >1.5 ml/kg or solid contents present on ultrasound 2

Additional Risk Factors Requiring Extra Vigilance

Patients at particularly high risk for aspiration include those with 2:

• Concomitant medications delaying gastric emptying (opioids, PPIs, tricyclic antidepressants) 2
• Recent recreational drug use (alcohol, cannabis) 2
• History of gastroesophageal surgery 2
• Inability to discontinue GLP-1 RA for three half-lives 2

The Glycemic Control Dilemma

The 2025 UK consensus acknowledges the tension between aspiration risk and worsening glycemic control from prolonged GLP-1 RA cessation 1. However, the consensus prioritizes safety by recommending cessation at least the day before surgery for most agents 1. For patients using GLP-1 RAs for diabetes management (not just weight loss), consult with the treating endocrinologist about risks versus benefits if the procedure cannot be postponed 5.

The evidence shows that perioperative hyperglycemia from stopping these medications is a legitimate concern, but the risk of pulmonary aspiration—a potentially fatal complication—takes precedence for elective procedures 6.

Critical Pitfalls to Avoid

• Do not rely on patient-reported fasting status alone—GLP-1 RAs cause delayed gastric emptying independent of fasting duration 1, 2
• Do not assume shorter-acting daily preparations are safe with standard fasting—even liraglutide requires 39 hours of cessation 2
• Do not underestimate aspiration risk with "light" MAC sedation—impaired consciousness compromises protective airway reflexes at any sedation level 5
• Do not proceed with elective surgery if adequate cessation time has not elapsed without implementing full aspiration precautions 1, 2

Patient Communication

Instruct all patients taking GLP-1 RAs to inform healthcare providers about these medications before any planned surgery or procedure 3, 4. This is now explicitly required in FDA labeling for these drugs.