GLP-1 Receptor Agonists: What Anesthesiologists Need to Know?

Abstract

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have rapidly transformed the management of type 2 diabetes mellitus and obesity and are increasingly used for cardio- vascular risk reduction and other metabolic indications. More recently, dual glucose- dependent insulinotropic polypeptide (GIP) and GLP-1 receptor agonists, particularly tirzepatide, have expanded the therapeutic landscape. The widespread use of these medications has created a new challenge for anesthesiologists because GLP-1 receptor activation delays gastric emptying, suppresses appetite, and may cause nausea, vomiting, abdominal distension, and constipation. These effects raise concern regarding residual gastric contents despite conventional fasting and the potential for regurgitation and pulmonary aspiration during sedation or general anesthesia. Early perioperative recommendations focused predominantly on withholding GLP-1RAs before procedures, with the American Society of Anesthesiologists (ASA) initially recommending omission of daily preparations on the day of surgery and weekly preparations for 1 week before surgery. However, subsequent evidence and multidisciplinary consensus statements have shifted toward an individualized, risk-stratified approach rather than routine discontinuation. Current guidance from major international organizations generally supports continuation of GLP-1-based therapy for most patients while emphasizing assessment of gastrointestinal symptoms, treatment escalation, dose, comorbid conditions, type of procedure, and aspiration risk. High-risk patients may benefit from a 24-h liquid diet, point-of-care gastric ultrasonography, modification of the anesthetic technique, or, in selected circumstances, rapid-sequence induction and tracheal intubation. For anesthesiologists, the key issue is not simply whether a patient has taken a GLP-1RA, but whether the patient is likely to have clinically significant residual gastric contents at the time of anesthesia. This review summarizes the pharmacology, physiological effects, perioperative risks, current evidence, evolving recommendations, and practical anesthetic management of patients receiving GLP-1RAs and GLP-1/GIP receptor agonists.