How long should a patient with diabetes or metabolic syndrome, scheduled for open heart bypass surgery, be off Glucagon-like peptide (GLP) medications before the procedure?

GLP-1 Receptor Agonists Before Open Heart Bypass Surgery

For patients on GLP-1 receptor agonists (like semaglutide, dulaglutide, or liraglutide) scheduled for open heart bypass surgery, discontinue weekly formulations for 3 weeks and daily formulations for 3-4 days before the procedure to prevent life-threatening pulmonary aspiration from retained gastric contents. 1, 2

Specific Discontinuation Timeline by Medication Type

Weekly GLP-1 Receptor Agonists

• Semaglutide (Ozempic, Wegovy): Stop 3 weeks (21 days) before surgery 1, 2
• Dulaglutide (Trulicity): Stop 2-3 weeks before surgery 1
• The American Society of Anesthesiologists' initial recommendation of only 1 week is now considered inadequate, as studies show discontinuation for only 7 days does not decrease retained gastric contents 2

Daily GLP-1 Receptor Agonists

• Liraglutide (Victoza, Saxenda): Stop 3-4 days before surgery 1

Critical Mechanism of Risk

GLP-1 receptor agonists create a persistent "full stomach" risk through multiple mechanisms that are particularly dangerous during cardiac surgery requiring general anesthesia 1, 2:

• They inhibit gastric peristalsis and increase pyloric tone, causing profound delays in gastric emptying 2
• 24.2% of patients on these medications have residual gastric content compared to 5.1% of controls, even after 12+ hours of fasting 2
• Multiple case reports document pulmonary aspiration requiring ICU admission in patients who fasted 18-20 hours and stopped medication 4-6 days before surgery 2

Special Considerations for Cardiac Surgery Patients

Diabetes vs. Weight Loss Indication

• For weight loss patients: Hold medication for the full 3 weeks without exception, as aspiration risks clearly outweigh any benefits 1, 2
• For diabetic patients: Consult cardiology and endocrinology to weigh glycemic control risks against aspiration risk, as some evidence suggests benefits of glycemic control may outweigh delayed gastric emptying concerns in diabetic cardiac patients 2, 3

Heart Failure Patients on GLP-1 Receptor Agonists

• Some patients may be taking these medications for heart failure indications rather than diabetes or weight loss 1
• Cessation may worsen heart failure status, requiring careful risk-benefit assessment with the cardiac team 1

If Adequate Holding Period Not Achieved

When surgery cannot be delayed and medication has not been stopped for adequate duration 1, 2:

1. Proceed with full stomach precautions including rapid sequence intubation with complete airway protection
2. Perform point-of-care gastric ultrasound pre-operatively to assess for residual gastric contents (target <1.5 ml/kg)
3. Administer prokinetic drugs such as metoclopramide or erythromycin pre-operatively
4. Avoid supraglottic airways entirely, as case reports document aspiration events with these devices
5. Consider pre-emptive gastric decompression in very high-risk patients

Additional Perioperative Cardiac Surgery Considerations

The 2011 ACC/AHA guidelines for CABG do not specifically address GLP-1 receptor agonists but emphasize other critical perioperative medication management 4:

• Continue aspirin (100-325 mg daily) preoperatively and restart within 6 hours postoperatively 4
• Stop clopidogrel/ticagrelor at least 5 days before elective surgery and prasugrel at least 7 days before 4
• Continue statin therapy throughout the perioperative period 4
• Use continuous intravenous insulin postoperatively to maintain glucose ≤180 mg/dL 4

Critical Pitfalls to Avoid

• Do not rely on standard fasting guidelines alone for patients on GLP-1 receptor agonists—retained gastric contents persist despite extended fasting 2
• Do not assume one week discontinuation is adequate for weekly formulations, as emerging evidence demonstrates this is insufficient 2
• Do not restart GLP-1 therapy until the patient is eating and drinking normally postoperatively, usually 24-48 hours after surgery 1
• Document pre-operative symptoms of nausea, vomiting, or abdominal distention, as these indicate even higher risk and may require procedure postponement 2

SGLT2 Inhibitor Management (If Also Applicable)

If your patient is also on SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin), these require separate management 1:

• Stop canagliflozin, dapagliflozin, and empagliflozin ≥3 days before surgery
• Stop ertugliflozin ≥4 days before surgery
• This prevents euglycemic diabetic ketoacidosis, a distinct complication from the aspiration risk of GLP-1 receptor agonists