GLP-1 and Surgery: The Complete Pre-Op Protocol

Planning surgery while taking a GLP-1 medication? The guidelines have evolved significantly. Early recommendations to stop medication weeks before surgery have been refined based on new evidence and patient outcomes.

This article covers the current (October 2024) multi-society guidance, why it matters, and exactly what you need to communicate to your surgical team.

Why GLP-1 Medications Matter for Surgery

GLP-1 medications raise surgical concerns because of one primary effect: delayed gastric emptying.

These medications slow how quickly food moves from your stomach to your small intestine. This is helpful for weight loss (you feel full longer) and blood sugar control (nutrients absorb more gradually). But for surgery requiring anesthesia, it creates a problem: food or liquid remaining in your stomach increases aspiration risk.

Early reports of patients with retained stomach contents despite following standard fasting protocols led to the initial recommendation to stop GLP-1 medications well before surgery. But newer guidance recognizes this was likely overcautious for most patients.

The October 2024 Multi-Society Guidance

In October 2024, the American Society of Anesthesiologists, along with multiple other medical societies, released updated guidance that takes a more nuanced approach:

This is a significant shift from earlier, more restrictive recommendations. The data showed that blanket requirements to stop medication weeks in advance weren't necessary for most patients and caused harm through diabetes destabilization and weight regain.

Who Can Continue, Who Should Modify

Continue GLP-1 as Usual (Low Risk)

• No GI symptoms (no significant nausea, vomiting, bloating)
• Stable dose (no increase in past 4 weeks)
• Following standard pre-operative fasting
• No history of gastroparesis

Modify Preparation (Higher Risk)

• Active GI symptoms: nausea, vomiting, bloating, early satiety
• Recent dose escalation (within past 2-4 weeks)
• History of gastroparesis or significant GI dysmotility
• Very high doses or multiple GI-affecting medications

For higher-risk patients, the recommendation is:

Medication-Specific Timing (If Holding Is Chosen)

Some surgeons or anesthesiologists may still prefer to hold GLP-1 medications, especially for longer or higher-risk procedures. If your team recommends stopping:

These timings are based on half-lives: weekly medications take longer to clear, so holding a single dose provides adequate washout for most patients.

What to Tell Your Surgical Team

Clear communication prevents problems. Before any procedure involving sedation or anesthesia, ensure your team knows:

Many anesthesiologists aren't yet familiar with the updated guidance. Having this information ready—and potentially a printout of the multi-society recommendations—helps ensure appropriate decision-making.

Emergency Surgery

For emergency surgery, there's no time to hold medications. The approach:

• Inform the anesthesiologist that you're on a GLP-1 medication
• Expect more aggressive gastric assessment
• May receive point-of-care gastric ultrasound to assess stomach contents
• Rapid-sequence intubation may be used to reduce aspiration risk
• Gastric decompression (nasogastric tube) may be placed

Emergency teams are trained to manage patients with full stomachs; GLP-1 use doesn't make emergency surgery unsafe, just requires appropriate precautions.

Post-Operative Considerations

When to Resume

• If you held medication: Resume when you're tolerating oral intake normally
• If you continued medication: Continue your regular schedule
• After GI surgery: Discuss timing with your surgeon; may need longer delay

Post-Op Nausea Considerations

GLP-1 medications can worsen post-operative nausea. Options include:

• Aggressive anti-nausea medication during recovery
• Temporary dose reduction if restarting after holding
• Slower advancement of diet

Blood Sugar Management

If you take GLP-1 medications for diabetes:

• Blood sugar may rise if you held the medication
• Coordinate with your diabetes care team
• May need temporary insulin coverage during surgical period
• Resume GLP-1 as soon as appropriate to regain glucose control

Specific Procedure Considerations

GI Procedures (Endoscopy, Colonoscopy)

Procedures visualizing the GI tract have special concerns:

• Upper endoscopy: Food in stomach impairs visualization; 24-hour liquid diet often recommended
• Colonoscopy: Standard prep usually sufficient; the aggressive cleanout clears the system
• Some gastroenterologists recommend holding GLP-1 before upper endoscopy regardless

Bariatric Surgery

Patients seeking bariatric surgery while on GLP-1 medications present unique considerations:

• Many surgeons recommend stopping GLP-1 before surgery to establish baseline eating patterns
• Post-bariatric GLP-1 use for weight regain is increasingly common
• Discuss your specific situation with your bariatric surgeon

Plastic/Cosmetic Surgery

These elective procedures allow full planning:

• Many plastic surgeons were early adopters of GLP-1 holding recommendations
• Current guidance suggests most patients can continue
• Discuss with your surgeon; their comfort level matters for elective procedures

If Your Surgeon Insists on Stopping

Some surgeons may still require stopping GLP-1 medications before surgery, even if updated guidelines suggest otherwise. Your options:

1. Ask about the rationale: Is it institutional policy, personal preference, or specific to your case?
2. Share the updated guidance: The October 2024 multi-society recommendations may not be on every surgeon's radar
3. Offer alternatives: Would a 24-hour liquid diet satisfy their concerns?
4. Respect their expertise: If they have specific concerns about your case, their judgment matters
5. Plan for the hold: If stopping is required, plan diabetes management and expect potential weight fluctuation

The Bottom Line

The landscape has evolved from "stop GLP-1 medications weeks before any surgery" to a more nuanced approach:

• Most patients can continue GLP-1 medications for elective surgery with standard fasting
• Higher-risk patients (GI symptoms, recent dose changes) may benefit from a 24-hour liquid diet
• If holding is required, skip one weekly dose or hold daily dosing the day of procedure
• Always inform your anesthesiologist—this is non-negotiable for safety
• Resume when tolerating oral intake normally after surgery

Surgery while taking GLP-1 medications is safe with appropriate precautions. The key is communication, individualized assessment, and following current evidence-based guidance.