Should Glucagon-like peptide-1 (GLP-1) receptor agonists be stopped before an epidural injection?

GLP-1 Management for Epidural Injections

For epidural injections performed under moderate sedation or local anesthesia without airway instrumentation, GLP-1 receptor agonists do NOT need to be stopped, as the aspiration risk is minimal in these procedures. However, if deep sedation or general anesthesia is planned, follow full perioperative guidelines for drug cessation.

Risk Stratification by Procedure Type

The critical distinction is whether the epidural injection requires airway management:

Low-Risk Scenarios (Continue GLP-1)

• Epidural steroid injections performed under local anesthesia or minimal-to-moderate sedation do not require GLP-1 cessation 1
• These procedures maintain protective airway reflexes and pose negligible aspiration risk even with delayed gastric emptying 1
• Standard preprocedural fasting (clear liquids up to 2 hours before) is sufficient 1

High-Risk Scenarios (Consider Cessation)

• If the procedure requires general anesthesia or deep sedation with loss of protective airway reflexes, treat as a full surgical case 2
• For weekly GLP-1 agents (semaglutide, dulaglutide, tirzepatide): hold for 1 week prior 2
• For daily GLP-1 agents (liraglutide, lixisenatide): hold on the day of procedure 2
• The American Society of Anesthesiologists recommends these cessation intervals specifically for procedures requiring airway instrumentation 2

Evidence Behind the Distinction

The aspiration concern with GLP-1 therapy stems from delayed gastric emptying, with studies showing retained gastric contents in 56% of patients on GLP-1 agents despite standard fasting 2. However, this risk only translates to clinical harm when protective airway reflexes are compromised 2.

• Pulmonary aspiration has been reported with an odds ratio of 10.23 (95%CI 2.94-35.82) in elective surgical settings requiring general anesthesia 2
• No similar data exists for procedures performed under local anesthesia or conscious sedation 1
• The 2025 Australian/New Zealand consensus recommends continuing GLP-1 therapy perioperatively for most procedures, with risk mitigation strategies rather than routine cessation 1

Practical Algorithm for Epidural Injections

Step 1: Identify the sedation level planned

• Local anesthesia only → Continue GLP-1, standard fasting 1
• Moderate sedation (responsive to verbal/tactile stimuli) → Continue GLP-1, standard fasting 1
• Deep sedation or general anesthesia → Proceed to Step 2

Step 2: If deep sedation/general anesthesia required

• Weekly agents: Hold for 1 week 2
• Daily agents: Hold on procedure day 2
• If patient has NOT held medication appropriately → Proceed to Step 3

Step 3: Risk mitigation if GLP-1 not held

• Perform point-of-care gastric ultrasound to assess residual gastric contents 2, 3
• Consider IV erythromycin as prokinetic agent 1
• Use rapid sequence intubation if general anesthesia required 2, 3
• Implement 24-hour clear liquid diet prior to procedure if time permits 1

Critical Considerations for Diabetes Patients

In patients taking GLP-1 for type 2 diabetes, the benefits of continuing therapy may outweigh aspiration risks 2. The evidence shows:

• Continuing GLP-1 until closer to surgery provides benefits in perioperative glycemic control and potential reduction in major adverse cardiac events 2, 3
• If cessation is necessary, bridge with alternative diabetes therapy during the cessation period 3
• Consult endocrinology regarding risks/benefits of holding for 3 half-lives (approximately 3 weeks for semaglutide) 3

Common Pitfalls to Avoid

• Do not assume standard fasting times are adequate - retained gastric contents occur despite 8-12 hour fasting in patients on GLP-1 agents 4
• Do not rely on absence of GI symptoms for risk stratification - patients can have retained gastric contents without nausea or vomiting 1
• Do not assume short discontinuation periods eliminate risk - discontinuation for 7 days may not decrease prevalence of retained gastric contents for long-acting agents 4
• Document the specific GLP-1 agent, dose, and last administration date in the preprocedural assessment 4

FDA Labeling Warnings

Both exenatide and liraglutide FDA labels now include warnings about pulmonary aspiration during general anesthesia or deep sedation, instructing patients to inform healthcare providers of any planned surgeries or procedures 5, 6. However, these warnings specifically reference general anesthesia and deep sedation, not procedures under local anesthesia 5, 6.