What are the anesthetic guidelines for perioperative use of Glucagon-like peptide-1 (GLP-1) receptor agonists?

Perioperative Management of GLP-1 Receptor Agonists

Primary Recommendation

For patients taking GLP-1 receptor agonists for weight loss, hold the medication for at least three half-lives before elective procedures; for patients with type 2 diabetes, consult endocrinology regarding the risks and benefits of holding versus continuing, as the glycemic and cardiovascular benefits may outweigh aspiration risks in this population. 1

Medication Timing by Agent

The three half-life rule clears approximately 88% of the drug and varies significantly by agent: 1, 2

• Semaglutide (weekly): Hold for 3 weeks (half-life = 7 days) 2
• Dulaglutide (weekly): Hold for 13-14 days (half-life = 4.5-4.7 days) 2
• Liraglutide (daily): Hold for 39 hours (half-life = 13 hours) 2

Risk Stratification Algorithm

Step 1: Document Critical Information 1

• Indication (diabetes vs. weight loss), specific agent, dose, and last administration date 1
• Symptoms of nausea, vomiting, or abdominal distention 1
• Concomitant medications delaying gastric emptying (opioids, PPIs, tricyclic antidepressants) 1
• Recent alcohol or cannabis use 1

Step 2: Apply Indication-Based Strategy 1

Weight Loss Indication:

• Mandatory hold for three half-lives before elective procedures 1, 2
• Higher doses used for weight loss prolong gastric stasis more than diabetes doses 1
• The risks outweigh benefits in this population 1

Type 2 Diabetes Indication:

• Consult endocrinology to weigh aspiration risk against glycemic control and cardiovascular benefits 1
• Continuing GLP-1 RAs provides superior perioperative glycemic control and potential reduction in major adverse cardiac events 1
• If holding medication, arrange bridging diabetic therapy 1

Step 3: Assess High-Risk Features 1, 2

Proceed with enhanced aspiration precautions if any of the following apply:

• Unable to hold medication for three half-lives 1
• Recently started medication or dose escalation 1
• Active gastrointestinal symptoms (nausea, vomiting, distention) 1
• Six days or less since weekly injection 2

Risk Mitigation Strategies

If Proceeding Despite Inadequate Washout Period 1, 2

1. Consider postponement of elective procedures until three half-lives have elapsed 1, 2

2. Implement aspiration risk reduction: 1

   • Clear liquid diet for extended period before standard fasting 1
   • Prokinetic agents (metoclopramide or erythromycin) preoperatively 1, 2
   • Point-of-care gastric ultrasound to assess residual contents (gastric volume <1.5 mL/kg indicates lower risk) 1, 2
   • Pre-emptive gastric decompression in very high-risk patients 1

3. Modify anesthetic technique: 1, 2

   • Rapid sequence intubation for general anesthesia 1, 2
   • Consider pure local anesthesia without sedation if feasible 2
   • Avoid light sedation, as impaired consciousness compromises protective airway reflexes even without deep sedation 2

FDA-Mandated Warnings

Both liraglutide and dulaglutide FDA labels explicitly warn that these agents delay gastric emptying and that rare postmarketing reports document pulmonary aspiration in patients undergoing elective procedures despite adherence to fasting guidelines. 3, 4 Available data are insufficient to determine whether modifying fasting or temporarily discontinuing medication reduces aspiration incidence. 3, 4 Patients must inform healthcare providers about GLP-1 RA use before any planned surgery or procedure. 3, 4

Critical Pitfalls to Avoid

• Do not rely solely on standard fasting guidelines – case reports demonstrate aspiration despite extended fasting periods in GLP-1 RA patients 2, 5
• Do not assume six days is adequate for weekly preparations – this provides insufficient clearance for semaglutide and dulaglutide 2
• Do not underestimate aspiration risk with light sedation – any level of sedation impairs protective reflexes 2
• Do not treat all GLP-1 RAs identically – daily agents like liraglutide have dramatically shorter washout periods than weekly agents 2
• Do not ignore the diabetes indication distinction – the risk-benefit calculation differs fundamentally between weight loss and diabetes management 1

Shared Decision-Making

Engage patients in open discussion about risks and benefits of each management option, particularly when balancing aspiration risk against glycemic control in diabetes patients. 1 The decision to proceed, postpone, or modify the anesthetic approach should incorporate patient values and procedural urgency. 1

Emerging Evidence Considerations

One recent case series of 57 patients undergoing endoscopic sleeve gastroplasty while continuing GLP-1 RAs showed no aspiration events when using a 24-hour liquid diet and 12-hour fast, 6 though this conflicts with broader safety concerns and should not override current consensus guidelines given the limited sample size and specific procedural context. 1, 5