What medications should a patient stop taking prior to undergoing gastric sleeve surgery?

Medications to Stop Prior to Gastric Sleeve Surgery

For patients undergoing gastric sleeve surgery, GLP-1 receptor agonists (semaglutide, liraglutide, dulaglutide) should be continued through surgery with full aspiration risk mitigation strategies, while SGLT-2 inhibitors must be stopped the day before and day of surgery. 1

GLP-1 Receptor Agonists (Semaglutide, Liraglutide, Dulaglutide)

Primary Recommendation: Continue Through Surgery

The 2025 multidisciplinary consensus from the Association of Anaesthetists, British Obesity and Metabolic Surgery Society, and multiple other societies recommends continuing GLP-1 receptor agonists perioperatively rather than stopping them. 1 This represents the most recent and highest-quality guideline evidence available.

Critical Aspiration Risk Mitigation Required

While continuing these medications, you must implement comprehensive aspiration risk reduction strategies: 1

• Perform full preoperative risk assessment and stratification documenting medication details, gastrointestinal symptoms, duration of therapy, and recent dose changes 1, 2
• Use point-of-care gastric ultrasound to assess residual gastric contents (target <1.5 ml/kg) 1, 3
• Administer prokinetic drugs such as metoclopramide or erythromycin preoperatively 1, 3
• Implement rapid-sequence intubation with full airway protection rather than supraglottic airways 1, 3
• Consider pre-emptive gastric decompression in very high-risk patients 1

Important Context on Conflicting Evidence

Earlier 2024 guidelines suggested stopping weekly GLP-1 receptor agonists for 3 weeks before surgery 1, but the 2025 consensus specifically recommends continuation with risk mitigation instead. 1 This shift reflects recognition that:

• Stopping these medications for weight loss patients undergoing bariatric surgery contradicts the therapeutic goal 1
• Glycemic control benefits in diabetic patients outweigh aspiration risks when proper precautions are taken 1, 2
• Even 3-week discontinuation doesn't guarantee empty stomach, as 24.2% of patients had retained gastric contents despite extended holding periods 3

High-Risk Scenarios Requiring Extra Vigilance

Patients at particularly elevated risk who need enhanced monitoring include: 1, 3

• Those who recently started medication or increased dose
• Those experiencing nausea, vomiting, or abdominal distention
• Those on concurrent medications delaying gastric emptying (opioids, proton pump inhibitors, tricyclic antidepressants)

SGLT-2 Inhibitors (Empagliflozin, Dapagliflozin, Canagliflozin)

Stop SGLT-2 inhibitors the day before and the day of surgery due to euglycemic ketoacidosis risk. 1, 2 This recommendation is unequivocal across all recent guidelines.

• Restart as soon as clinically feasible postoperatively 2
• Monitor for signs of ketoacidosis perioperatively even with normal glucose levels 1

Cardiovascular Medications to Continue

Beta-Blockers

Continue all beta-blockers perioperatively without interruption to avoid severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias. 2

Statins

Continue statins perioperatively without interruption, as discontinuation is potentially harmful. 2

ACE Inhibitors/ARBs

Consider holding ACE inhibitors and ARBs on the day of surgery due to increased risk of intraoperative hypotension requiring vasopressor support, but restart as soon as clinically feasible postoperatively. 2

Antiplatelet Therapy Management

Aspirin

Continue aspirin in patients on secondary prevention; may discontinue 7-10 days before surgery for primary prevention only if bleeding risk exceeds cardiac risk. 2

P2Y12 Inhibitors (Clopidogrel, Ticagrelor)

Discontinue at least 5 days before elective surgery to reduce major bleeding risk. 2

Diabetes Medications Beyond GLP-1 RAs

Basal Insulin

Continue basal insulin at reduced dose perioperatively, targeting postoperative glucose <180 mg/dL to reduce infection risk. 2

Psychiatric Medications

Antidepressants (SSRIs, SNRIs, TCAs)

Continue all antidepressants perioperatively to avoid withdrawal syndrome. 2 Monitor for serotonin syndrome if multiple serotonergic agents are used concurrently. 2

NSAIDs: Special Consideration for Sleeve Gastrectomy

NSAIDs may be used cautiously after sleeve gastrectomy, as research shows no association between NSAID exposure and peptic ulcers specifically after sleeve gastrectomy (unlike gastric bypass where continuous use ≥30 days significantly increases ulcer risk). 4 However, institutional policies often prohibit NSAID use across all bariatric patients. 5

Common Pitfalls to Avoid

• Do not stop GLP-1 receptor agonists based on older 2024 guidelines—the 2025 consensus supersedes these recommendations 1
• Do not assume standard fasting guidelines are sufficient for patients on GLP-1 receptor agonists—gastric ultrasound and aspiration precautions are mandatory 1, 3
• Do not forget to restart SGLT-2 inhibitors postoperatively once clinically appropriate 2
• Do not use supraglottic airways in patients on GLP-1 receptor agonists—case reports document aspiration with these devices 1, 3