ASA tells anesthesiologists to hold GLP-1 drugs before elective procedures

The American Society of Anesthesiologists (ASA) released consensus-based guidance on June 29, 2023 telling anesthesiologists how to handle patients — adults and children — who take GLP-1 receptor agonists before elective surgery or procedures requiring general anesthesia or deep sedation ^[1]. The core suggestion: consider holding daily-dosed GLP-1 drugs on the day of the procedure, and holding weekly-dosed drugs for a week beforehand ^[1].

The concern is delayed gastric emptying. GLP-1 drugs slow how fast the stomach empties, which is part of how they curb appetite, but it also raises the possibility that food remains in the stomach even after a patient follows standard fasting instructions ^[1]. If stomach contents come back up during anesthesia, they can be inhaled into the lungs — known as regurgitation and pulmonary aspiration ^[1].

What the guidance actually says

The ASA task force said the hold applies regardless of why the drug was prescribed — type 2 diabetes or weight loss — and regardless of dose or the type of procedure ^[1]. If a GLP-1 drug prescribed for diabetes is held longer than the normal dosing schedule, the guidance suggests consulting an endocrinologist about bridging other diabetes therapy to avoid high blood sugar ^[1].

On the day of the procedure, the guidance lays out three paths ^[1]. If a patient has symptoms such as severe nausea, vomiting or retching, abdominal bloating or abdominal pain, clinicians should consider delaying the elective procedure and discussing aspiration risk with the surgeon and patient. If there are no GI symptoms and the drug was held as advised, proceed as usual. If there are no symptoms but the drug was not held, the team should either use "full stomach" precautions or consider a gastric ultrasound to check stomach volume, if available and the clinician is skilled with it; an empty stomach means proceeding normally, while a full or inconclusive result means considering a delay or managing the case as a full stomach ^[1].

For urgent or emergency procedures, the guidance says to proceed but treat the patient as having a full stomach ^[1]. The ASA also said there is no evidence on the optimal fasting time for people on GLP-1 drugs, so its existing fasting guidelines still apply ^[1].

How strong is the evidence

The ASA was blunt about the limits. It described the evidence for preoperative management of these drugs as "sparse," limited to several case reports, and said the concerns were based on "recent anecdotal reports" ^[1]. Supporting citations include a retrospective analysis of residual gastric content in patients on semaglutide undergoing elective upper endoscopy, a study of gastric residue during esophagogastroduodenoscopy, and a single case report of aspiration during anesthesia in a patient on semaglutide ^[1].

The guidance also notes a counterpoint: the effect on gastric emptying is reported to diminish with long-term use, likely because of rapid tachyphylaxis — the body adapting — at the level of vagal nerve activation ^[1]. The ASA's own drug table lists semaglutide's gastric emptying delay at about 60 minutes with a half-life of roughly one week, and dulaglutide's delay at about 120 minutes, largest after the first dose ^[1].

Why it matters for patients

If you take a weekly injection such as semaglutide (Ozempic, Wegovy) and have an elective procedure scheduled, this guidance means your anesthesia team may ask you to skip a dose about a week out, and may ask detailed questions about nausea, bloating or vomiting on the morning of surgery ^[1]. It also means a procedure could be postponed, or handled with extra airway precautions, if the drug was not held or if symptoms are present ^[1].

For people using these drugs for diabetes, holding a dose raises the separate issue of blood sugar control, which is why the ASA points to endocrinology input for bridging therapy ^[1]. The guidance does not set a fasting duration different from the usual one ^[1]. How often aspiration actually occurs in people on GLP-1 drugs is not established in this document — the ASA itself says the evidence base is case reports ^[1].

What happens next

The ASA notes that in October 2024 it issued an Affirmation of Value for a newer, multi-society guidance document on GLP-1 drugs, meaning the June 2023 advice has been superseded by later multi-specialty recommendations ^[1]. The drug table accompanying the 2023 statement carries a last-update date of November 1, 2024 ^[1]. Details of the multi-society guidance are not contained in this source.