ASA Advises No Longer Holding GLP-1 Agents Prior to Surgery for Most Patients

Most patients should not stop taking GLP-1 receptor agonists prior to elective surgery, according to updated guidance from several medical societies, including the American Society of Anesthesiologists (ASA).

This recommendation, published in Surgery for Obesity and Related Diseases, is in stark contrast to 2023 guidance from the ASA, which originally advised a 1-week and 1-day hold of injectable and oral GLP-1 agents, respectively, prior to surgery. Because these popular weight-loss and diabetes drugs delay gastric emptying, the thinking was that a drug hiatus would reduce the risk of aspiration and regurgitation under anesthesia.

However, the new guidance — signed off by the ASA, American Gastroenterological Association, American Society for Metabolic and Bariatric Surgery, International Society for Perioperative Care of Patients with Obesity, and the Society of American Gastrointestinal and Endoscopic Surgeons — said this no longer applies to the majority of patients. Instead, most can continue their medication up until the day of surgery, but should follow a liquid diet for 24 hours before the procedure, depending on the specific circumstances.

“As anesthesiologists, we are committed to considering all factors to ensure patients get the best and safest care whenever anesthesia care is required,” said ASA President Donald E. Arnold, MD, in a statement. “In many cases, patients with scheduled procedures should continue taking the drug. Scheduling of elective procedures should integrate awareness of circumstances when the risk of delayed stomach emptying is highest, such as when the patient is just beginning the drug and the dose is being increased, as well as for patients with significant GI [gastrointestinal] symptoms.”

“Ideally, these risk factors should be assessed and minimized in advance, so the surgery or procedure can safely proceed,” he added.

According to the guidance, care teams should consider the following factors when individually weighing a patient’s metabolic need for the GLP agent with risks during the perioperative period:

• If patients are in the dose-escalation phase (associated with greater delayed gastric emptying) versus the maintenance phase
• Higher dose (e.g., 2.4 mg of semaglutide [Wegovy] vs 1 mg [Ozempic])
• Weekly dosing (which has more gastrointestinal side effects) versus daily dosing
• Presence of gastrointestinal side effects suggestive of delayed gastric emptying
• Medical conditions beyond GLP-1 usage that may also delay gastric emptying (e.g., bowel dysmotility, gastroparesis, Parkinson’s disease)

“The assessment for these risk factors should occur with enough advance time prior to surgery to allow adjustments in preoperative care if indicated, including diet modification and evaluation of the feasibility of medication bridging if GLP-1 RA [receptor agonist] discontinuation is indicated,” the guidance noted.

If there is still cause for concern the day of surgery, point-of-care gastric ultrasound could be used to assess aspiration risk. However, this technology “may be clinically limited based on institutional resources, interuser variability, and credentialing requirements,” the guidance authors wrote.

These updates come on the heels of several recent studies looking into a GLP-1 hiatus prior to surgery that has divided anesthesiologists, with some research indicating a low aspiration risk with GLP-1 use, and other studies suggesting the opposite.

Ultimately, the guidance emphasizes shared decision making between “the patient, the prescribing care team, the proceduralist or surgeon, and the anesthesiologist,” noted guidance co-author Girish P. Joshi, MBBS, MD, vice chair of ASA’s Committee on Practice Parameters, and colleagues in a corresponding letter to the editor published in Anesthesiology. They advised that healthcare providers strike a balance between aspiration risk with the risks associated with stopping a GLP-1 receptor agonist, such as hyperglycemia, which could further complicate surgeries.