As blogged previously here and here, much controversy exists as to whether, when, in whom, or for how long GLP1 based medications should be held prior to receiving anesthesia or sedation for surgery or procedures like colonoscopy. The concern is that case reports have emerged where people taking GLP1-based medications had been found to have food in the stomach despite following the usual fasting procedures, and even cases of aspiration of stomach content into the lungs, which can be life threatening.  GLP1 based medications are used for treatment of diabetes and for weight management, and include semaglutide (Ozempic / Rybelsus / Wegovy), tirzepatide (Mounjaro / Zepbound), liraglutide (Victoza / Saxenda), dulaglutide (Trulicity), and others.

A new consensus statement published in Anaesthesia takes another crack at this challenging topic. A key difference to this guidance is that diabetes specialty organizations and specialists were included (in addition to several anesthesia and obesity organizations) – a glaring omission to last year’s guidance documents. On the other side of the coin, gastroenterologists were not included in this statement, which would have been valuable to have a full circle of key specialties at the table.

The biggest difference from prior guidance is their recommendation that patients should continue to take GLP1 receptor agonists throughout the perioperative period, whereas prior guidance has advised us to hold medication for a week or longer. (see my prior comments re the lack of merit of holding medication for one week). They comment that the prior blanket guidance to hold medication for a week (for once weekly medication) doesn’t accomplish much , as this is still associated with a high risk of having residual gastic content in those who fasted appropriately for surgery. A meaningful hold would be 5 weeks to get the medication out of the system completely, and holding medication for that long would come with unnecessary risks.

They recommend also that:

  • the risk of pulmonary aspiration and mitigation strategies should be discussed with the patient using a shared decision-making approach.
  • patients and clinicians should adhere to recommended fasting guidelines.
  • upper GI symptoms (eg nausea) alone should not be used to determine gastric content (as not having GI symptoms on GLP1 medication does not rule out the possibility of slowed GI transit)
  • regional anesthesia (ie without sedation) should be considered if appropriate.
  • gastric ultrasound at the time of the surgery/procedure should be considered (to see if stomach is empty or not).
  • individualized assessment of aspiration risk should be completed, accounting for the medication, patient, and procedural factors. (Note – this should include an assessment for other medications that can increase risk of aspiration)
  • anesthesia and airway management should aim to reduce risk of aspiration.

I like the guidance from the 2024 documents that suggest a preoperative liquid diet for at least 24 hours before anesthesia/sedation, which isn’t included in this 2025 guidance. As it is solid food in the stomach that is problematic, it makes sense to give more time before the surgery/procedure without solid food intake. Authors quite correctly point out that research and data are needed to objectively evaluate preoperative dietary modifications.

BOTTOM LINE: We are still far from clear answers on exactly what should be done to mitigate the very rare risk of aspiration with anesthesia or sedation for people taking GLP1-based medication. This guidance does not replace the 2024 guidance, but gives different advice, with different viewpoints and specialists at the table. This guidance recommends that people should generally continue to take their GLP1-based medication through the perioperative period, with other strategies advised to mitigate risk.

Disclaimer: I am/have been an investigator in clinical trials of semaglutide, tirzepatide, and dulaglutide.   I receive honoraria as a continuing medical education speaker and consultant from the makers of semaglutide (Novo Nordisk), tirzepatide and dulaglutide (Eli Lilly).

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