Praxis Medical Insights

Est. 2024 • Clinical Guidelines Distilled

Made possible by volunteer editors from the University of Calgary & University of Alberta

Last Updated: 8/14/2025

Diabetes Management

Medication Adjustment

  • Patients with diabetes may require adjustment of other diabetes medications during the transition period, as recommended by various guideline societies 1
  • GLP-1 receptor agonists should be discontinued for at least three half-lives before elective surgery and resumed only after adequate oral intake has been established postoperatively, due to the risk of delayed gastric emptying, regurgitation, and pulmonary aspiration, as recommended by the American Society of Anesthesiologists and the American College of Anaesthesiologists 2, 3
  • Discontinuation of GLP-1 RAs may lead to hyperglycemia, and alternative glucose management strategies should be implemented during the perioperative period, with patients who have lost significant weight on GLP-1 RAs requiring screening for malnutrition before surgery, as recommended by Diabetes Care and the American Diabetes Association 4, 5

  • When discontinuing GLP-1 receptor agonists, a tapering protocol should be used, such as:

    Agent Tapering Protocol
    Weekly GLP-1 RAs (e.g., semaglutide) Reduce dose by 50% for 4 weeks, then further reduce to 25% of the maximum dose for an additional 4 weeks before discontinuation
    Daily GLP-1 RAs (e.g., liraglutide) Reduce dose by 0.6 mg increments every 2 weeks, with follow-up visits every 4-6 weeks to monitor for weight changes, return of hunger/cravings, and changes in metabolic parameters
  • After surgery, patients may require different dosing of GLP-1 RAs or alternative weight management strategies, with the need to resume GLP-1 RAs only after adequate oral intake has been established, following standard dose titration protocols to minimize gastrointestinal side effects, as recommended by the American Diabetes Association and the American Association of Clinical Endocrinologists 6, 7, 2, 5
  • Patients should be monitored for at least three half-lives after discontinuation of GLP-1 RAs to ensure resolution of side effects, and provided with supportive care for persistent gastrointestinal symptoms, including adequate hydration, anti-emetics, and prokinetic agents like metoclopramide, as recommended by the American Diabetes Association and the American Association of Clinical Endocrinologists 2, 5
  • Proper documentation of GLP-1 RA indication and dose, date drug commenced, dose variations, last dose taken, presence of gastrointestinal symptoms, and co-prescribed drugs that can delay gastric emptying is essential, and the anesthesiologist should be informed about GLP-1 RA use and the timing of the last dose, as recommended by the American Society of Anesthesiologists and the American College of Anaesthesiologists 2, 3
  • Consideration should be given to using prokinetic agents, such as metoclopramide, preoperatively to reduce the risk of aspiration, and point-of-care gastric ultrasound to assess residual gastric contents, as well as employing rapid sequence intubation technique, as recommended by the American College of Anaesthesiologists and the American Society of Anesthesiologists 2, 3
  • The decision to stop GLP-1 RAs should involve shared decision-making with patients, discussing the risks and benefits of each option before the procedure, and considering risk reduction strategies such as postponement and rescheduling of the procedure, clear fluid diet, prokinetic drugs, point-of-care gastric ultrasound, rapid-sequence intubation, and pre-emptive gastric decompression in high-risk patients, as recommended by the American College of Anaesthesiologists and the American Society of Anesthesiologists 2

Perioperative Care

  • Patients on GLP-1 RAs should be closely monitored for signs of hyperglycemia and malnutrition during the perioperative period, and alternative glucose management strategies should be implemented as needed, as recommended by Diabetes Care and the American Diabetes Association 4, 5
  • The use of prokinetic agents, such as metoclopramide, and point-of-care gastric ultrasound can help reduce the risk of aspiration and pulmonary complications in patients on GLP-1 RAs, as recommended by the American College of Anaesthesiologists and the American Society of Anesthesiologists 2, 3

Risk Reduction Strategies

  • Risk reduction strategies, such as postponement and rescheduling of the procedure, clear fluid diet, prokinetic drugs, point-of-care gastric ultrasound, rapid-sequence intubation, and pre-emptive gastric decompression, should be considered in high-risk patients on GLP-1 RAs, as recommended by the American College of Anaesthesiologists and the American Society of Anesthesiologists 2
  • Shared decision-making with patients is essential when discussing the risks and benefits of stopping GLP-1 RAs before surgery, and considering alternative weight management strategies, as recommended by the Endocrine Society and the American Heart Association 2

REFERENCES

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