Should dulaglutide (Trulicity) be held before surgery in an adult patient with type 2 diabetes?

Should Dulaglutide (Trulicity) Be Held Before Surgery?

Yes, dulaglutide must be held for one week (7 days) before elective surgery to minimize the risk of pulmonary aspiration from delayed gastric emptying. 1

Evidence-Based Holding Period

The 2025 multidisciplinary UK consensus statement from the Association of Anaesthetists and multiple specialty societies explicitly recommends stopping weekly GLP-1 receptor agonists like dulaglutide one week before the procedure. 1 This recommendation applies specifically to weekly formulations and is based on:

• Pharmacokinetic rationale: Dulaglutide has a prolonged elimination half-life that requires extended discontinuation to allow gastric emptying to normalize 1
• Aspiration risk: GLP-1 receptor agonists delay gastric emptying through their mechanism of action, creating a risk of retained gastric contents even after standard fasting periods 1

Why Standard Fasting Is Insufficient

Multiple case reports and observational studies demonstrate that patients on GLP-1 receptor agonists retain gastric contents despite prolonged fasting:

• Patients who fasted 18-20 hours and stopped dulaglutide 4-6 days before surgery still experienced regurgitation and pulmonary aspiration 1
• In one case series, a patient on dulaglutide 1.7 mg weekly who fasted for 10 hours (solids) and 4 hours (clear fluids) still aspirated during induction 1
• Endoscopy studies show 24.2% of patients on semaglutide (a similar weekly GLP-1 RA) had residual gastric contents after 12+ hours fasting and 10-14 days off the drug, versus only 5.1% of controls 1

Critical Aspiration Risk Data

The magnitude of aspiration risk is substantial:

• Odds ratio of 10.23 (95% CI 2.94-35.82) for pulmonary aspiration in elective surgery settings among GLP-1 RA users 1
• Hazard ratio of 1.33 (95% CI 1.02-1.74) in endoscopy settings 1
• Patients on chronic GLP-1 RA therapy show retained gastric contents in 5.4% versus 0.5% in controls (p=0.004), even with 12+ hour fasting 1

Practical Implementation Algorithm

For elective surgery:

• Hold dulaglutide 7 days (one full week) before the scheduled procedure 1
• Schedule the patient as the first case of the morning to minimize additional fasting time 1
• Consider gastric ultrasound if there is concern about retained contents, particularly in patients who recently started therapy 1
• Use rapid sequence intubation techniques if aspiration risk remains a concern 1

For semi-urgent/urgent surgery:

• If dulaglutide cannot be held for the full week, treat the patient as having a full stomach 1
• Employ aspiration precautions including rapid sequence intubation and cricoid pressure 1
• Consider point-of-care gastric ultrasound to assess gastric volume 1

Important Caveats

Tachyphylaxis uncertainty: While some data suggest the gastric emptying effect may diminish with chronic use, the evidence remains conflicting and cannot be relied upon for safety 1. Multiple case reports document aspiration in patients on long-term therapy (months to years). 1

Duration of therapy matters: Patients recently started on dulaglutide (within 4-8 weeks) appear to have higher risk, with 7 out of 10 patients showing solid gastric contents on ultrasound despite 10-hour fasting in one study 1

Weight loss vs. diabetes indication: The aspiration risk applies regardless of whether dulaglutide is prescribed for diabetes or weight loss 1

Postoperative Restart Considerations

Do not restart dulaglutide at hospital discharge. 2 The drug requires a minimum 3-week discontinuation period before gastric emptying normalizes (approximately three half-lives). 2 Before restarting:

• Confirm the patient tolerates oral intake without nausea, vomiting, or abdominal distention 2
• Ensure no signs of delayed gastric emptying 2
• For diabetic patients, consider endocrinology consultation to balance glycemic control against ongoing aspiration risk 2

Glycemic Management During Holding Period

While dulaglutide is held, maintain glycemic control with:

• Target blood glucose 5-10 mmol/L (90-180 mg/dL) perioperatively 1
• Use continuous intravenous regular insulin infusion if needed during surgery 1
• Monitor blood glucose every 1-2 hours intraoperatively 1
• Avoid overly strict targets (<5 mmol/L or <90 mg/dL) which increase hypoglycemia risk without improving outcomes 1