Five medical societies reverse course: most patients can keep taking GLP-1 drugs before surgery

Five US medical societies released joint clinical practice guidance on October 29, 2024, saying most patients should continue taking their GLP-1 receptor agonist medications before elective surgery, rather than automatically stopping them ^[2]. Patients judged to be at the highest risk for gastrointestinal problems should follow a liquid diet for 24 hours before the procedure, or take other steps depending on their situation ^[2].

The guidance comes from 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 ^[2]. It was published in Surgical Endoscopy and other society journals ^[1].

What changed

The underlying concern has not changed: GLP-1 drugs slow stomach emptying, so food can remain in the stomach even after standard fasting ^[1][2]. That raises the risk of regurgitation and aspiration of stomach contents into the airway and lungs during general anesthesia and deep sedation, which can cause potentially fatal aspiration pneumonia ^[2]. The guidance document notes there have been reports of pulmonary aspiration in patients on GLP-1 drugs undergoing sedation or general anesthesia ^[1].

What changed is the response. Earlier documents from different organizations were inconsistent, leaving clinicians uncertain about how to care for these patients ^[1]. The new guidance replaces a one-size-fits-all hold with shared decision-making among the patient, the procedural team, the anesthesia team and the prescribing clinician, balancing the metabolic need for the drug against each patient's individual risk ^[1]. The societies recommend that practices build their own multidisciplinary protocols ^[1].

The guidance lists specific factors that raise the risk of delayed stomach emptying ^[1]:

• Being in the dose escalation phase rather than the maintenance phase. ASA says escalation typically lasts four to eight weeks, depending on the drug and why it was prescribed, and that elective surgery should be deferred until escalation has passed and GI side effects have faded ^[2].
• Being on a higher dose, which is linked to more GI side effects. These patients should follow a liquid diet for 24 hours before the procedure ^[1][2].
• Weekly rather than daily dosing, which is associated with more GI side effects ^[1].
• Current GI symptoms such as nausea, vomiting, abdominal pain, dyspepsia, shortness of breath or constipation. Patients should wait until symptoms have resolved before elective surgery ^[1][2].
• Other conditions that slow stomach emptying, such as bowel dysmotility, gastroparesis or Parkinson's disease ^[1][2].

For patients at highest risk, the team can also adjust the anesthesia plan to reduce aspiration risk and use point-of-care ultrasound right before the procedure to check stomach contents ^[2]. In rare cases, surgery should be delayed when the risk is expected to decrease ^[2]. Patients at low risk who are having elective surgery can continue their GLP-1 drug, the guidance says ^[2].

Why it matters for patients

About one in eight US adults use GLP-1 drugs such as Ozempic (semaglutide), Wegovy (semaglutide), Saxenda (liraglutide) and Trulicity (dulaglutide) for diabetes, weight loss or heart problems, according to ASA ^[2]. Until now, many of them were told to stop the drug before any procedure.

The societies argue that stopping carries its own costs. Withholding a GLP-1 drug can raise blood sugar in people with diabetes, can be resource intensive, and may be cost- or insurance-prohibitive ^[2]. The stated goal is to let surgery proceed safely "without removing the benefit of their GLP-1 drugs any longer than necessary" ^[2].

The guidance also addresses fairness directly: withholding GLP-1 drugs only for patients with obesity or overweight could constitute bias or discrimination and should be avoided ^[2]. The document covers patients taking these drugs for any approved indication, including type 2 diabetes, overweight and obesity, and heart failure ^[1].

Practically, this means the conversation before a procedure is likely to be more detailed than a simple "stop it" instruction. ASA advises that patients work with their anesthesiologist, surgeon and prescribing team to decide whether adjustments allow surgery to proceed or whether it should be delayed ^[2].

One important caveat: the societies acknowledge there are limited data to construct fully evidence-based guidelines ^[1]. This is practice guidance built on expert consensus, not a conclusion from large randomized trials. Whether following it reduces actual aspiration events has not been established in the sources.

What happens next

The guidance was accepted September 9, 2024, and released publicly October 29, 2024 ^[1][2]. ASA President Donald E. Arnold said scheduling of elective procedures should build in awareness of when the risk of delayed stomach emptying is highest, so risk factors can be assessed and minimized in advance ^[2]. How quickly individual hospitals and surgery centers rewrite their own pre-op instructions is not addressed in the sources.