Perioperative Management of GLP-1 and GIP Receptor Agonists (Including Tirzepatide): Current Guidelines

Key takeaways#

General direction of guidelines (2024-2025)

• The 2024-2025 trend is not to routinely discontinue GLP-1 agonists (and GIP/GLP-1 co-agonists).
• Most patients can continue until surgery, as long as risk is low.

How to decide without "autopilot"

• The key is to stratify risk of delayed gastric emptying (GI symptoms and patient factors) and mitigate when necessary (24h liquid diet, fasting adjustments, airway management with "full stomach" precautions).
• Discontinuing may not "zero out" the risk and can carry metabolic cost (e.g., glycemic decontrol). Therefore, societies have converged on case-by-case decision-making.

If discontinuing, timing matters

• When discontinuation is indicated, timing varies by pharmacokinetics: 1 day (short-acting) vs 7 days (long-acting).

Tools that help when there's uncertainty

• If point-of-care gastric ultrasound and expertise are available, it can help decision-making, especially in uncertain scenarios.

Why has this become mandatory in anesthesiology?#

The use of GLP-1 agonists (and GIP/GLP-1 co-agonists, like tirzepatide) has brought a specific concern to anesthesiology: the possibility of delayed gastric emptying with risk of aspiration during sedation/anesthesia.

Therefore, the discussion focuses on how to reduce the risk of "full stomach" without causing metabolic harm by interrupting therapies that support glycemic and/or weight control.

What explains the variation between recommendations?#

Societies have converged on more risk-based management rather than "automatic" approaches, partly because there's no guarantee that stopping the drug prevents aspiration and because there are relevant clinical effects from interruption (e.g., glycemic decontrol).

Some consensus statements highlight studies finding residual gastric content even weeks after discontinuing the medication, which reduces the value of universal discontinuation as a sole strategy.

Since this is a controversial topic, below are recommendations from major anesthesiology and endocrinology societies worldwide.

Recommendations by society#

American Society of Anesthesiologists (ASA)

In October 2024, the ASA endorsed a multi-society guideline, highlighting the following points:

• Do not recommend routine discontinuation: most patients can continue the GLP-1 agonist until surgery.
• Stratify risk: identify patients at high risk for GI effects (nausea, fullness, reflux).
• In higher-risk cases, recommend 24-hour liquid diet, possibility of extended fasting, and adjustments to airway management plan (e.g., rapid sequence induction with airway protection).
• If risk is clearly very high (clearly full stomach, persistent vomiting), consider postponing elective procedure.

American Diabetes Association (ADA)

The 2024-2025 guidelines incorporated perioperative recommendations aligned with multidisciplinary consensus, focusing on case-by-case decisions.

When to continue (low risk)

• In low-risk patients (no significant GI symptoms, chronic and well-tolerated GLP-1 analog use, and no other gastroparesis factors), it's acceptable to continue the GLP-1 analog until surgery day.
• Aspiration risk in these patients is low, and stopping the medication could harm metabolic control.

When to intensify measures (elevated risk)

• In patients with elevated risk of delayed gastric emptying (e.g., symptoms of nausea, vomiting, abdominal distension, prior diabetic gastroparesis, severe obesity, or significant reflux), ADA suggests additional measures:

  • consider 24-hour liquid diet before surgery protocol
  • apply "full stomach" precautions during anesthesia (e.g., endotracheal intubation, rapid sequence) if needed
  • or even temporarily discontinue the GLP-1 analog in the most concerning cases

If choosing to discontinue the medication in a patient with diabetes, implement alternative glycemic control therapy (e.g., basal/rapid insulin) to avoid uncontrolled perioperative hyperglycemia.

Generally, ADA endorses an individualized approach: not all patients should have GLP-1 discontinued, nor can all continue without assessment. The balance between aspiration risk vs. need for metabolic stability should guide case-by-case management.

This guidance applies to both GLP-1 agonists and dual GIP/GLP-1 agonists (like tirzepatide), given the similarity of gastrointestinal effects.

Brazilian Society of Anesthesiology (SBA) + Brazilian Diabetes Society (SBD)

The SBA/SBD 2025 guideline seeks to balance aspiration risk from delayed gastric emptying versus metabolic risk from discontinuation.

When to continue

• In adapted patients (>12 weeks of use with stable dose), without significant GI effects and without comorbidities that delay gastric emptying, no prophylactic discontinuation is needed.

When to discontinue

• Patients with less than 12 weeks of use or dose escalation, with GI symptoms (nausea, vomiting, distension, dyspepsia) or aspiration risk factors:

  • gastroparesis
  • poorly controlled diabetes
  • obesity
  • history of aspiration or neuromuscular diseases
  • chronic opioid use
  • tricyclic antidepressants
  • anticholinergics
  • proton pump inhibitors
  • calcium channel blockers

• Long-acting GLP-1 or GLP-1/GIP analogs (e.g., weekly semaglutide, dulaglutide, tirzepatide; also oral semaglutide and high-dose liraglutide): discontinue 7 days before.

• Short-acting GLP-1 or GLP-1/GIP analogs (e.g., usual DM doses of liraglutide, lixisenatide): discontinue 1 day before.

• If diabetes: ensure glycemic control with insulin or other means during discontinuation period.

General preparation and safety measures (whether continuing or discontinuing)

• Liquid-only diet for 24 hours before, followed by 8-12 hours absolute fasting before induction.
• Consider point-of-care gastric ultrasound when available and with expertise.
• Emphasis on individualized decision-making and coordination between endocrinologist, anesthesiologist, and surgeon.

Australia: ANZCA + Australian Diabetes Society (ADS)

Consensus (April 2025) with ANZCA/ADS and additional endorsements (GESA, NACOS), with general approach of no routine discontinuation and structured mitigation:

• Do not routinely discontinue before surgeries/endoscopies.
• Actively ask about use during pre-anesthetic assessment (including weight loss use without formal registration).
• 24-hour liquid diet before surgery + standard fasting: 24h of clear liquids and at least 6h fasting for solids.
• If inadequate diet/uncertainty: consider gastric US, prokinetics, or technique adjustment (e.g., rapid sequence intubation, intubation instead of laryngeal mask, elevated head of bed); if clearly unfavorable findings (full stomach/vomiting), postpone elective procedure.
• Attention to comorbidities that worsen gastric emptying (e.g., gastroparesis, motility disorders, Parkinson's).

Association of Anaesthetists of Great Britain and Ireland (AAGBI)

Multidisciplinary consensus (Anaesthesia, 2025) with recommendation to continue GLP-1 and GIP/GLP-1 agonists perioperatively:

• Patients should continue using glucagon-like peptide-1 (GLP-1) receptor agonists throughout the perioperative period.

• Follow preoperative fasting recommendations.

• Upper gastrointestinal symptoms alone should not be used to determine residual gastric content.

• Regional anesthesia should be considered as the primary anesthetic technique, when appropriate.

• Point-of-care gastric ultrasound should be considered before anesthesia induction to facilitate risk stratification, when appropriate.

• An individualized assessment of pulmonary aspiration risk should be performed, considering drug, patient, and procedure-related factors.

• Anesthesia and airway management should aim to reduce pulmonary aspiration risk at anesthesia induction, during maintenance, and after emergence. This may include:

  • administration of prokinetics
  • use of tracheal tube
  • modified rapid sequence intubation (with or without cricoid pressure, depending on local practice)
  • head-elevated position for anesthesia induction
  • potential use of gastric tube to empty stomach before anesthesia induction and before tracheal extubation
  • awake tracheal extubation

Discontinuation timing when guideline indicates interruption#

How to translate guidelines into practical decisions without "autopilot"#

What appears in common across guidelines is a simple mental framework:

1. Confirm use and context (GLP-1 or GIP/GLP-1; chronic use vs starting/escalating).
2. Check delayed emptying risk (GI symptoms and patient factors).
3. If low risk, tendency is to continue.
4. If increased risk, apply mitigations (24h liquid diet, fasting adjustments, "full stomach" airway strategy).
5. If risk is very high (e.g., persistent vomiting / clearly full stomach), consider postponing elective.
6. If opting to discontinue in diabetes, ensure alternative plan for glycemic control.

Conclusion#

Together, the most recent guidelines (2024-25) converge on personalized management, unlike initial recommendations from some years ago of "discontinue in all cases."

In most scenarios, medication continuation is possible as long as the diet the day before surgery and adequate fasting are followed.

When discontinuation is indicated, timing varies by pharmacokinetics (1 day for short duration; 7 days or more for long duration). If point-of-care ultrasound is available and the anesthesiologist is proficient, bedside assessment can greatly help decision-making regarding airway approach.

In all scenarios, individualization and shared decision-making between anesthesiologist, endocrinologist, and surgeon remain central, always with patient participation.

Where does AnestCopilot fit in this story (without taking you out of control)#

If you want to organize preoperative assessment and prevent medication decisions from becoming a marathon of tabs, Pre-op Meds – Preoperative Medication Manager helps quickly structure "continue, discontinue, adjust, or substitute" within the perioperative flow.

And when the topic requires depth, Deep Evidence – Scientific Research Engine accelerates literature review in language applicable to daily practice.

Related reading#

• AI Revolutionizing Anesthesiology: From Machine Learning to AnestCopilot
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