Perioperative Management of GLP-1 Receptor Agonists

Introduction to Risks

GLP-1 receptor agonists, such as semaglutide, significantly delay gastric emptying, creating risks for pulmonary aspiration even with local anesthesia procedures, as documented in multiple case reports, according to the American Society of Anesthesiologists 1

Patients on semaglutide may still have significant gastric contents even with extended fasting of 18-20 hours, posing a risk for aspiration, as noted by the American Society of Anesthesiologists 1
Procedures can be stratified into higher risk (involving sedation, supine positioning, or airway manipulation) and lower risk (minor procedures with upright positioning and minimal sedation) categories, based on expert opinion 1

For patients using GLP-1 RAs for weight loss, the American College of Surgeons recommends withholding medication for at least three half-lives (approximately 3 weeks for semaglutide) before elective surgery, based on moderate-quality evidence 1, 2
For patients using GLP-1 RAs for diabetes management, consultation with the treating endocrinologist is recommended to weigh the risks and benefits of holding the medication, with consideration of the impact on glycemic control versus aspiration risk, based on low-quality evidence 1
When GLP-1 RAs cannot be discontinued for sufficient time, consideration should be given to postponement of elective procedures or implementation of aspiration risk reduction strategies, including:

Inadequate discontinuation time and assuming standard fasting is sufficient are potential pitfalls in managing patients on semaglutide, as highlighted by the American Society of Anesthesiologists 1
For urgent/emergent procedures where semaglutide cannot be discontinued, the patient should be treated as having a full stomach regardless of fasting time, according to the American Society of Anesthesiologists 1
The use of point-of-care gastric ultrasound can help identify patients at high risk of aspiration, with a strength of evidence based on observational studies 1
Failing to identify GLP-1 RA use, especially in patients taking semaglutide for weight loss, can increase the risk of pulmonary aspiration, with a strength of evidence based on case reports 1