Five medical societies back keeping GLP-1 drugs before elective surgery

Five US medical societies issued joint guidance on October 29, 2024 that moves away from automatically stopping GLP-1 medications before elective surgery. Under the new approach, most patients continue their drug, and risk is judged patient by patient instead ^[2].

The document was published in the journal Surgical Endoscopy and carries the endorsement of the American Society of Anesthesiologists (ASA), the American Gastroenterological Association, the American Society for Metabolic and Bariatric Surgery, the International Society of Perioperative Care of Patients with Obesity and the Society of American Gastrointestinal and Endoscopic Surgeons ^[1][2].

Roughly one in eight American adults uses a GLP-1 drug, a category that includes Ozempic (semaglutide), Wegovy (semaglutide), Saxenda (liraglutide) and Trulicity (dulaglutide), taken for diabetes, weight loss or heart conditions, according to the ASA ^[2]. These medicines slow the stomach's emptying, so food can remain in the stomach longer than usual. During general anesthesia or deep sedation, that leftover content can travel back up and be inhaled into the lungs, causing aspiration pneumonia, which can be fatal ^[2].

The societies concluded that the benefit of an automatic drug pause is not clear-cut, because interrupting treatment can push blood sugar up in people with diabetes and can bring cost, insurance and scheduling problems. The guidance also warns that singling out patients with obesity or overweight for a hold could amount to discrimination and should not happen ^[2].

Low-risk patients having elective procedures may simply stay on their medication ^[2]. For those judged highest risk, the options include a liquid-only diet for the 24 hours leading up to the procedure, an anesthesia plan adjusted to lower aspiration risk, and a point-of-care ultrasound immediately before the procedure to look at what is in the stomach ^[2]. Occasionally, surgery should be postponed so that risk can fall ^[2].

Several characteristics push a patient into the higher-risk group, according to the document ^[1][2]:

• Being in the escalation phase, the period when the dose is stepped up, which lasts about four to eight weeks depending on the drug and the reason it was prescribed ^[2].
• Taking a larger dose ^[1][2].
• Using a weekly product rather than a daily one, since weekly formulations are tied to more gastrointestinal side effects ^[1].
• Having symptoms such as nausea, vomiting, belly pain, constipation or shortness of breath ^[1][2].
• Having a separate condition that also slows stomach emptying, among them gastroparesis, bowel dysmotility and Parkinson's disease ^[1][2].

For those still ramping up their dose, elective surgery should wait until the escalation phase is over and GI symptoms have eased, the guidance states. The same applies to patients with active GI symptoms, who should wait for them to clear first ^[2].

Decisions are meant to be shared among the patient and the procedural, anesthesia and prescribing teams, and each practice is expected to write its own multidisciplinary protocol ^[1].

"In many cases, patients with scheduled procedures should continue taking the drug," ASA President Donald E. Arnold, M.D., FACHE, FASA, said in the announcement. He added that risk factors should ideally be assessed and minimized in advance so the procedure can safely proceed ^[2].

Why it matters for patients

The practical effect is a shift in what happens in the weeks before a procedure. Earlier statements from different organizations did not line up, leaving patients and clinicians unsure whether a GLP-1 drug had to be stopped ^[1]. Now there is one shared framework to work from, and for most people it points toward staying on treatment ^[2].

A patient's preparation may therefore hinge on questions like how long they have been taking the drug, whether the dose is currently being increased, whether they have digestive symptoms, and whether another condition affects stomach emptying ^[1][2]. Because hospitals and surgery centers are expected to build their own protocols, instructions may differ from one facility to the next ^[1]. The document does not give a set number of days to stop a GLP-1 drug before surgery, and no single stop-time rule is set out in it ^[1][2].

What happens next

The guidance appeared in Surgical Endoscopy with a 2025 issue date, having been accepted September 9, 2024 ^[1]. A companion letter to the editor in the journal Anesthesiology was authored by Girish P. Joshi, M.D., FASA, a guidance coauthor and vice chair of the ASA Committee on Practice Parameters ^[2]. The authors note that the evidence base for formal guidelines is thin ^[1]. How quickly individual hospitals and surgery centers put the recommendations into practice has not been reported.