When should GLP-1 (Glucagon-like peptide-1) receptor agonists, such as liraglutide (Victoza) or semaglutide (Ozempic), be stopped in patients with type 2 diabetes prior to elective surgery?

Preoperative Management of GLP-1 Receptor Agonists Before Elective Surgery

Primary Recommendation

For patients taking GLP-1 receptor agonists for weight loss, discontinue semaglutide and other weekly GLP-1 RAs for at least 3 weeks (three half-lives) before elective surgery; for patients with diabetes, consult endocrinology to weigh glycemic control risks against aspiration risk. 1, 2

Evidence-Based Holding Periods by Medication

Weekly GLP-1 Receptor Agonists

• Semaglutide (Ozempic, Wegovy): Hold for 3 weeks before surgery 1, 2
• Tirzepatide (Mounjaro, Zepbound): Hold for 3 weeks before surgery 2
• Dulaglutide (Trulicity): Hold for 2-3 weeks before surgery 2

Daily GLP-1 Receptor Agonists

• Liraglutide (Victoza, Saxenda): Hold for 3-4 days before surgery 2

The three half-life recommendation clears approximately 88% of the drug from the system, though this does not guarantee complete normalization of gastric emptying 1, 2.

Critical Evidence Supporting Extended Holding Periods

The standard 1-week holding period recommended by some older guidelines is insufficient. 1, 2 Key evidence includes:

• Discontinuation for only 7 days did not decrease the prevalence of retained gastric contents 1
• 24.2% of patients on semaglutide had residual gastric content compared to 5.1% of controls, even after 12+ hour fasting 2
• Multiple case reports document pulmonary aspiration requiring ICU admission in patients who fasted 18-20 hours and stopped semaglutide only 4-6 days before surgery 2

Mechanism of Aspiration Risk

GLP-1 receptor agonists delay gastric emptying through multiple mechanisms 1, 2:

• Inhibition of gastric peristalsis 1
• Increased pyloric tone 1
• Vagal nerve pathway activation 1
• These effects persist despite some tachyphylaxis with chronic use 3

This delayed gastric emptying creates a "full stomach" risk even with appropriate preoperative fasting. 1, 2

Distinction Between Diabetes and Weight Loss Indications

For Weight Loss Patients (Non-Diabetic)

Hold medication for the full 3 weeks without exception. 1, 2 The risks of continuing until shortly before surgery outweigh any benefits in patients using GLP-1 RAs for weight management 1, 2.

For Diabetes Patients

Consult with the treating endocrinologist regarding: 1

• Risks and benefits of holding the drug for at least three half-lives 1
• Recommendations for bridging diabetic therapy if the GLP-1 RA must be held longer than the next scheduled dosing time 1
• Potential detrimental effects on perioperative glycemic control from prolonged cessation 2

The benefits of GLP-1 RAs for glycemic control in diabetic patients may outweigh aspiration risks in some cases, requiring individualized decision-making with endocrinology input 2.

High-Risk Patient Identification

Consider patients at particularly high risk if they have: 1, 2

• Recently started the medication or increased their dose 1
• Current symptoms of nausea, vomiting, or abdominal distention 1
• Co-prescribed drugs that delay gastric emptying (opioids, proton pump inhibitors, tricyclic antidepressants) 1
• Recent use of recreational drugs that delay gastric emptying (alcohol, cannabis) 1
• Pre-existing digestive symptoms (require more than 21 days discontinuation) 2

Risk Mitigation Strategies When Adequate Holding Period Not Achieved

Postponement and Rescheduling

Consider postponing elective procedures if the medication has not been held for adequate duration. 1, 2 This is the safest option when feasible 1.

Preoperative Assessment

• Point-of-care gastric ultrasound: Inspect for residual gastric contents to guide decision-making (target gastric volume <1.5 ml/kg) 1, 2
• Prokinetic drugs: Consider metoclopramide or erythromycin preoperatively 1, 2
• Clear fluid diet: Implement for some period before standard preoperative fasting 1

Intraoperative Precautions

• Rapid-sequence intubation: Use to reduce pulmonary aspiration risk 1, 2
• Avoid supraglottic airways: Case reports show aspiration with these devices; choose endotracheal intubation 2
• Pre-emptive gastric decompression: Consider in very high-risk patients 1, 2
• Treat as "full stomach" case: Implement all aspiration precautions 2

Preoperative Documentation Requirements

Document the following in the preoperative assessment: 1

• Indication and dose of GLP-1 receptor agonist 1
• Date drug commenced, dose variations, last dose taken 1
• Symptoms of nausea, vomiting, or abdominal distention 1
• Co-prescribed drugs that can delay gastric emptying 1
• Recent intake of recreational drugs that delay gastric emptying 1
• Previous gastro-esophageal surgery 1

Common Pitfalls to Avoid

Do not assume standard fasting times are adequate. Even 18-20 hour fasting periods have resulted in aspiration in patients on GLP-1 RAs 2.

Do not rely on the 1-week holding period for weekly agents. This recommendation is outdated and insufficient based on current evidence 1, 2.

Do not forget that both oral and injectable formulations carry the same aspiration risk. The delayed gastric emptying effect applies to all GLP-1 RA formulations 2.

Do not discontinue GLP-1 RAs in diabetic patients without endocrinology consultation. Prolonged cessation may have detrimental effects on perioperative glycemic control 1, 2.

Shared Decision-Making Approach

Use a shared decision-making approach with patients to openly discuss: 1

• The risks of proceeding with surgery if medication has not been held adequately 1
• The benefits of postponing surgery to allow adequate medication clearance 1
• Alternative risk mitigation strategies if postponement is not feasible 1
• The balance between aspiration risk and glycemic control in diabetic patients 1