Anesthesiologists group advises holding GLP-1 drugs such as semaglutide before elective procedures
The guidance tells anesthesia teams to consider pausing drugs like Ozempic, Wegovy and Rybelsus before elective surgery, a decision patients may now be asked about at pre-surgical appointments.
The American Society of Anesthesiologists released consensus-based guidance on June 29, 2023, advising anesthesiologists to hold GLP-1 receptor agonists before elective procedures: about a week ahead for weekly injectables and on the day of the procedure for daily medicines [1]. The task force acted after case reports of food remaining in the stomach even when patients had followed standard fasting instructions [1].
The concern is delayed gastric emptying. GLP-1 agonists are associated with nausea, vomiting and slower emptying of the stomach, and the ASA task force wrote that this may increase the risk of regurgitation and pulmonary aspiration of stomach contents during general anesthesia and deep sedation [1]. The task force said the evidence available to guide preoperative management is sparse and limited to several case reports, including a report of intraoperative pulmonary aspiration in a patient on semaglutide and studies that found residual stomach contents in patients taking GLP-1 drugs who had elective upper endoscopy [1]. The guidance states that nausea, vomiting, dyspepsia and abdominal distension in patients taking these drugs are predictive of increased residual gastric contents [1].
The recommendations apply regardless of why the drug was prescribed — type 2 diabetes or weight loss — and regardless of dose or the type of procedure, according to the guidance [1]. For the day of the procedure, the ASA suggests that if gastrointestinal symptoms such as severe nausea, vomiting, retching, abdominal bloating or abdominal pain are present, clinicians consider delaying an elective procedure and discussing the risk of regurgitation and aspiration with the surgeon and the patient [1]. If there are no such symptoms and the drug was held as advised, the guidance says to proceed as usual [1]. If there are no symptoms but the drug was not held, the guidance suggests proceeding with "full stomach" precautions or checking gastric volume with ultrasound if the clinician is proficient; if the stomach is empty, proceed as usual, and if it is full or the ultrasound is inconclusive, consider delaying or managing the patient as having a full stomach [1]. For urgent or emergent procedures, the guidance says to proceed and treat the patient as having a full stomach [1].
The document notes there is no evidence on the optimal fasting duration for patients on GLP-1 agonists, so it recommends following current ASA fasting guidelines [1]. It also advises that if a GLP-1 drug prescribed for diabetes is held longer than its dosing schedule, clinicians consider consulting an endocrinologist to bridge the diabetes therapy and avoid high blood sugar [1].
A summary table in the guidance lists semaglutide (Ozempic, Wegovy, Rybelsus) as delaying gastric emptying by about 60 minutes with a half-life of roughly one week; dulaglutide (Trulicity) as delaying emptying by about 120 minutes, with the largest effect after the first dose and less with later doses; liraglutide (Saxenda, Victoza) with a median delay of 70 minutes; and exenatide (Byetta, Bydureon BCise) [1]. Tirzepatide, sold as Mounjaro and Zepbound, is not included in that table [1]. The guidance also says the effects on gastric emptying are reported to be reduced with long-term use, most likely through rapid tachyphylaxis at the level of vagal nerve activation [1]. Regarding children, it says the published literature covers mainly patients 10 to 18 years old and that concerns are similar to those in adults [1].
Why it matters for patients
Adults taking semaglutide or another GLP-1 drug may be asked about it at a pre-surgical visit, and a scheduled procedure could be delayed or handled differently based on whether the drug was paused and whether stomach symptoms are present [1]. The guidance is a consensus suggestion for anesthesia professionals, not a rule, and it leaves the decision to the clinical team and the patient [1]. For people who take a GLP-1 drug for type 2 diabetes, pausing it raises a separate issue: the ASA advises considering an endocrinology consult so blood sugar is managed in the meantime [1]. Nothing in the guidance changes the drugs' approved uses, and it does not say patients should stop these medicines outside the context of a planned procedure [1].
What happens next
The document is dated June 29, 2023, and its page carries a note that in October 2024 the ASA issued an "Affirmation of Value" for a more recent, multi-society GLP-1 guidance document [1]. The page lists a last update of November 1, 2024 [1]. Whether individual hospitals, surgery centers and clinics have adopted the 2023 suggestions as policy has not been reported [1].
Sources
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