Five major medical societies published joint clinical practice guidance in 2024 for managing glucagon-like peptide-1 receptor agonist (GLP-1RA) therapy during the perioperative period, addressing safety concerns about delayed gastric emptying and aspiration risk.

The guidance appeared in Clinical Gastroenterology and Hepatology, representing consensus from the American Gastroenterological Association, American Society for Metabolic and Bariatric Surgery, American Society of Anesthesiologists, International Society of Perioperative Care of Patients with Obesity, and Society of American Gastrointestinal and Endoscopic Surgeons.

The societies identified GLP-1 as part of the "ileal brake" mechanism, with receptor targets in the pancreas, brain, heart, kidney, and stomach. Current therapeutic indications include type 2 diabetes, overweight/obesity, and heart failure.

KEY RECOMMENDATIONS:

Risk Assessment Factors:

• Medication escalation phase versus maintenance phase
• Higher GLP-1RA dosing
• Weekly versus daily formulations
• Presence of gastrointestinal symptoms
• Concurrent medical conditions affecting gastric motility

Management Considerations:

• Assessment timing must allow for preoperative adjustments
• Discontinuation decisions require shared decision-making, balancing aspiration risk against potential metabolic complications
• If discontinuation is indicated, suggested holding periods (following ASA guidance):
  • Daily formulations: Hold day of surgery
  • Weekly formulations: Hold one week before surgery
• Consider limitations of bridging therapy: resource intensity, insurance barriers, hypoglycemia risk
• Avoid discontinuing solely for overweight/obesity to prevent bias

Risk Mitigation Steps:

• Minimum 24-hour preoperative liquid diet
• Optional point-of-care gastric ultrasound assessment (limited by institutional resources, user variability, and credentialing requirements)
• Rapid sequence induction for general anesthesia when indicated

The guidance received approval from the AGA Institute Governing Board, ASMBS Board of Directors, International Society of Perioperative Care of Patients with Obesity Board in April-June 2024, and SAGES Board of Directors, with affirmation from the ASA Administrative Council.

Case reports documented pulmonary aspiration during both procedural sedation and general anesthesia. Weekly formulations showed higher rates of gastrointestinal side effects compared to daily dosing.

The societies noted this represented guidance rather than evidence-based guidelines due to limited available data.