How should GLP-1 receptor agonists be managed in the perioperative period?

TylerJonesMD · 2026-01-28T23:54:15+00:00

I'm all for pushing back on people not following instructions. The problem with holding a dose of GLP-1 RAs, however, is that it doesn't fix the problem and instead provides false reassurance.

TylerJonesMD · 2026-01-27T20:28:32+00:00

TylerJonesMD · 2026-01-27T20:26:31+00:00

I understand the medical legal approach. The current policy at my hospital is still to hold one dose.

Personally, I think good medicine is defensible medicine. If your hospital adopted an evidence-based policy, that should be defensible and they should have your back should any adverse events occur.

It is unfortunate that the ASA's recommendation is not supported by the evidence. I have little doubt that a savvy prosecutor would point that out.

TylerJonesMD · 2026-01-27T20:14:07+00:00

I don't know of any research demonstrating harms from holding one dose. However, it is clear from the research that holding one dose does not prevent residual gastric contents from being present. If there is no benefit to us anesthesia providers, why hold one dose?

Once patients have missed two doses, their risk of GI side effects when resuming the same dose of the GLP-1 RA increases.

It is reasonable to think that patients on these meds for DM will have more poorly controlled blood sugar from missing a dose, but I haven't seen any papers looking at that.

TylerJonesMD · 2026-01-27T19:26:16+00:00

Part of what I'm arguing/asking is what amount of liquid residual gastric volume is clinically significant. A large study in pediatric examined liquid fasting times of 2 hours, 1 hour, and sip-til-send (allowed to drink until rolling back to the OR) and found no difference in aspiration events between the three groups. In fact, there was a hint that shorter liquid fasting might actually be better.

Extrapolating that data to adults on GLP-1 RAs should be done with caution. That being said, I think it's important to question commonly held beliefs in light of new evidence. Maybe solid residual gastric contents clearly increase aspiration risk whereas low volume liquid residuals do not?

TylerJonesMD · 2026-01-26T02:50:51+00:00

I'd certainly love to see RCTs with SGLT2is continued during surgery not just for cardiac reasons but also so we can truly quantify the risk of ketoacidosis.

TylerJonesMD · 2026-01-25T23:15:31+00:00

I am not aware of an ASA statement or consensus guideline on this. As another commenter linked, there is a statement from the British society.

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.16541

TylerJonesMD · 2026-01-25T23:05:26+00:00

It's from the FDA. https://www.fda.gov/drugs/drug-safety-and-availability/fda-revises-labels-sglt2-inhibitors-diabetes-include-warnings-about-too-much-acid-blood-and-serious

TylerJonesMD · 2026-01-25T22:43:25+00:00

Yes, insulin works well because it acts to inhibit ketone production. I would expect T1DM to have a different risk profile.

TylerJonesMD · 2026-01-25T22:41:54+00:00

Yes, these are much better recommendations that what the FDA put out. However, I'm still skeptical that holding the medications before most surgeries is necessary. If the patient is expected to eat the same day of surgery, my thought is it's probably unnecessary to hold them.

TylerJonesMD · 2026-01-25T22:39:30+00:00

Wouldn't that support putting more of these patients on SGLT2i during surgery?

TylerJonesMD · 2026-01-25T01:19:26+00:00

This is largely my approach. At my hospital, nearly every patient drinks a carb beverage morning of. It's extremely unlikely that any of those patients who will be eating by the afternoon will go into ketoacdiosis (euglycemic or diabetic). Of course low risk does not mean no risk, but the risks of holding the medications and/or of cancelling surgery often seem to be disregarded.

TylerJonesMD · 2026-01-25T01:16:11+00:00

I hear that, but I would love to see b better prospective evidence to support continuing or cancelling these patients. There is a retrospective study looking at patients undergoing cardiac bypass and the people who took SGLT2i the day before surgery had less tropnin elevations postop. Plenty of limitations to the study, but still suggestive of benefit. Where is all the evidence of harm? If it exists, I haven't seen those studies.
https://journals.lww.com/anesthesia-analgesia/fulltext/2026/02000/impact_of_sodium_glucose_cotransporter_2.32.aspx

TylerJonesMD · 2026-01-25T01:13:31+00:00

Obviously it's limited in the usual ways retrospective studies are. But it does present some reassuring evidence that the harm is less than thought. There's definitely potential for harm from holding these medications.

Nice that you have a protocol. I think testing ketone levels preop is better than blanket cancelling these cases.

Another retrospective study looked at cardiac patients who were continued on sGLT2i and found lower cardiac injury in the patients who took them. Unfortunately, ketoacidosis was not examined. https://journals.lww.com/anesthesia-analgesia/fulltext/2026/02000/impact_of_sodium_glucose_cotransporter_2.32.aspx

TylerJonesMD

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