Perioperative Management of GLP-1 Receptor Agonists

Preoperative Considerations

GLP-1 receptor agonists should be held for at least three half-lives before surgery, with specific timing based on the indication for use, to ensure approximately 88% of the drug is cleared 1
The American Society of Anesthesiologists' previous recommendation to withhold daily-dose GLP-1 therapy on the day of surgery and weekly-dose therapy for the week prior may be insufficient, particularly for long-acting agents 1
Patients recently started on GLP-1 receptor agonists or increased dose, experiencing nausea, vomiting, or abdominal distention, taking other medications that delay gastric emptying, or with recent intake of substances that delay gastric emptying, may require special consideration 1
Previous gastro-esophageal surgery is also a factor to consider when managing GLP-1 receptor agonists preoperatively 1

In high-risk patients or when unable to hold GLP-1 receptor agonist for three half-lives, consider prokinetic drugs (metoclopramide or erythromycin) pre-operatively, use point-of-care gastric ultrasound to assess residual gastric contents, and consider rapid sequence intubation to reduce aspiration risk 1
In very high-risk patients, consider pre-emptive gastric decompression 1

Maintain target blood glucose range of 100-180 mg/dL (5.6-10.0 mmol/L) preoperatively, as recommended by the American Diabetes Association 2
Monitor blood glucose every 2-4 hours while NPO, and use short or rapid-acting insulin as needed for glycemic control 2
Attempting overly tight glycemic control (<80-100 mg/dL) perioperatively increases hypoglycemia risk without improving outcomes 2

Resume GLP-1 receptor agonist therapy once patient is eating normally and metabolically stable 1
Discontinuing long-acting GLP-1 receptor agonists for only 7 days may not be sufficient to ensure an empty stomach pre-operatively 1

Failing to distinguish between patients taking GLP-1 receptor agonists for diabetes versus weight loss when making management decisions can lead to inadequate care 1
Consider prokinetic drugs, perform gastric ultrasonography, and use rapid sequence intubation if gastric volume >1.5 ml/kg or solid matter is present 1