INTERNATIONAL GUIDELINES ON PERIOPERATIVE MANAGEMENT OF GLP-1 RECEPTOR AGONISTS: A NARRATIVE REVIEW
Abstract
Background: The widespread use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in the treatment of diabetes mellitus and obesity has led to a growing number of patients receiving these agents presenting for surgical and procedural interventions. Their known effects on gastric motility have raised concerns regarding delayed gastric emptying and perioperative aspiration risk, prompting the publication of multiple professional society recommendations.
Objectives: This review aims to identify, compare, and critically analyse contemporary clinical practice guidelines addressing the perioperative management of patients treated with GLP-1 receptor agonists, with particular focus on drug continuation versus withholding, risk stratification, and mitigation strategies.
Methods: A narrative review of professional society guidelines published between 2020 and 2025 was conducted. A structured bibliographic database search and citation analysis identified official recommendations from anaesthesiology, diabetology, gastroenterology, and perioperative medicine societies. Guidelines were analysed with respect to recommendations on perioperative GLP-1 RA management, identification of high-risk patients, proposed risk mitigation strategies, and supporting evidence.
Results: Substantial heterogeneity was observed among guidelines. While early recommendations favoured routine discontinuation of GLP-1 RAs, more recent guidance supports an individualised, risk-based approach. Commonly identified risk factors include early treatment phase, dose escalation, higher doses, gastrointestinal symptoms, and comorbid conditions affecting gastric motility. Proposed mitigation strategies include dietary modification, selective drug withholding, gastric point-of-care ultrasound, and tailored anaesthetic techniques. Most recommendations are based on low-quality evidence and expert opinion.
Conclusions: Current guidance increasingly favours personalised perioperative management of GLP-1 RA–treated patients. High-quality prospective studies are needed to better define perioperative risk and inform evidence-based, harmonised recommendations.
References
Aschen, S. Z., Zhang, A., O’Connell, G. M., Salingaros, S., Andy, C., Rohde, C. H., & Spector, J. A. (2025). Association of Perioperative Glucagon-like Peptide-1 Receptor Agonist Use and Postoperative Outcomes. Annals of Surgery, 281(4), 600–607. https://doi.org/10.1097/SLA.0000000000006614
Baethge, C., Goldbeck-Wood, S., & Mertens, S. (2019). SANRA—a scale for the quality assessment of narrative review articles. Research Integrity and Peer Review, 4(1), 5. https://doi.org/10.1186/s41073-019-0064-8
Brown, E., Heerspink, H. J. L., Cuthbertson, D. J., & Wilding, J. P. H. (2021). SGLT2 inhibitors and GLP-1 receptor agonists: established and emerging indications. The Lancet, 398(10296), 262–276. https://doi.org/10.1016/S0140-6736(21)00536-5
Chang, M. G., & Bittner, E. A. (2024). Comparison of societal guidance on perioperative management of glucagon-like peptide-1 receptor agonists: implications for clinical practice and future investigations. Canadian Journal of Anesthesia/Journal Canadien d’anesthésie, 71(9), 1302–1315. https://doi.org/10.1007/s12630-024-02810-5
El‐Boghdadly, K., Dhesi, J., Fabb, P., Levy, N., Lobo, D. N., McKechnie, A., Mustafa, O., Newland‐Jones, P., Patel, A., Pournaras, D. J., Clare, K., & Dhatariya, K. (2025). Elective peri‐operative management of adults taking glucagon‐like peptide‐1 receptor agonists, glucose‐dependent insulinotropic peptide agonists and sodium‐glucose cotransporter‐2 inhibitors: a multidisciplinary consensus statement. Anaesthesia, 80(4), 412–424. https://doi.org/10.1111/anae.16541
ElSayed, N. A., McCoy, R. G., Aleppo, G., Balapattabi, K., Beverly, E. A., Briggs Early, K., Bruemmer, D., Echouffo-Tcheugui, J. B., Ekhlaspour, L., Galindo, R. J., Garg, R., Khunti, K., Lal, R., Lingvay, I., Matfin, G., Pandya, N., Pekas, E. J., Pilla, S. J., Polsky, S., … Bannuru, R. R. (2025). 16. Diabetes Care in the Hospital: Standards of Care in Diabetes—2025. Diabetes Care, 48(Supplement_1), S321–S334. https://doi.org/10.2337/dc25-S016
Facciorusso, A., Ramai, D., Dhar, J., Samanta, J., Chandan, S., Gkolfakis, P., Crinò, S. F., Maida, M., Anderloni, A., Boskoski, I., Triantafyllou, K., Dinis-Ribeiro, M., Hassan, C., Fuccio, L., & Arvanitakis, M. (2025). Effects of Glucagon-Like Peptide-1 Receptor Agonists on Upper Gastrointestinal Endoscopy: A Meta-Analysis. Clinical Gastroenterology and Hepatology, 23(5), 715-725.e3. https://doi.org/10.1016/j.cgh.2024.07.021
Giannakogeorgou, A., & Roden, M. (2024). Role of lifestyle and glucagon‐like peptide‐1 receptor agonists for weight loss in obesity, type 2 diabetes and steatotic liver diseases. Alimentary Pharmacology & Therapeutics, 59(S1). https://doi.org/10.1111/apt.17848
Girish P. Joshi, Basem B. Abdelmalak, Wade A. Weigel, Sulpicio G. Soriano, Monica W. Harbell, & Catherine I. Kuo. (2023). American Society of Anesthesiologists Consensus-Based Guidance on Preoperative Management of Patients (Adults and Children) on Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists.
Gudzune, K. A., & Kushner, R. F. (2024). Medications for Obesity. JAMA, 332(7), 571. https://doi.org/10.1001/jama.2024.10816
Guideline for Perioperative Care for People with Diabetes Mellitus Undergoing Elective and Emergency Surgery. (2021). Centre for Perioperative Care (CPOC).
Haskins, S. C., Bronshteyn, Y. S., Ledbetter, L., Arzola, C., Kalagara, H., Hardman, D., Panzer, O., Weber, M. M., Heinz, E. R., Boublik, J., Cubillos, J., Hernandez, N., Zimmerman, J., & Perlas, A. (2025). ASRA pain medicine narrative review and expert practice recommendations for gastric point-of-care ultrasound to assess aspiration risk in medically complex patients undergoing regional anesthesia and pain procedures. Regional Anesthesia & Pain Medicine, rapm-2024-106346. https://doi.org/10.1136/rapm-2024-106346
Hocking, S. L., Scott, D. A., Remedios, M. L., Horowitz, M., Story, D. A., Greenfield, J. R., Boussioutas, A., Devereaux, B., Andrikopoulos, S., Shaw, J. E., & Olesnicky, B. L. (2025). 2025 ADS/ANZCA/GESA/NACOS clinical practice recommendations on the peri-procedural use of GLP-1/GIP receptor agonists. Anaesthesia and Intensive Care, 53(5), 300–306. https://doi.org/10.1177/0310057X251355288
Jalleh, R. J., Marathe, C. S., Rayner, C. K., Jones, K. L., Umapathysivam, M. M., Wu, T., Quast, D. R., Plummer, M. P., Nauck, M. A., & Horowitz, M. (2024). Physiology and Pharmacology of Effects of GLP-1-based Therapies on Gastric, Biliary and Intestinal Motility. Endocrinology, 166(1). https://doi.org/10.1210/endocr/bqae155
Jalleh, R. J., Plummer, M. P., Marathe, C. S., Umapathysivam, M. M., Quast, D. R., Rayner, C. K., Jones, K. L., Wu, T., Horowitz, M., & Nauck, M. A. (2024). Clinical Consequences of Delayed Gastric Emptying With GLP-1 Receptor Agonists and Tirzepatide. The Journal of Clinical Endocrinology & Metabolism, 110(1), 1–15. https://doi.org/10.1210/clinem/dgae719
Kamarajah, S. K., Gudiozzi, N., Findlay, J. M., Lee, M. J., Pinkney, T., & Markar, S. R. (2025). Evaluation of safety of preoperative GLP-1 receptor agonists in patients undergoing elective surgery: a systematic review, meta-analysis and meta-regression. EClinicalMedicine, 87, 103408. https://doi.org/10.1016/j.eclinm.2025.103408
Kindel, T. L., Wang, A. Y., Wadhwa, A., Schulman, A. R., Sharaiha, R. Z., Kroh, M., Ghanem, O. M., Levy, S., Joshi, G. P., & LaMasters, T. L. (2024). Multisociety clinical practice guidance for the safe use of glucagon-like peptide-1 receptor agonists in the perioperative period. Surgery for Obesity and Related Diseases, 20(12), 1183–1186. https://doi.org/10.1016/j.soard.2024.08.033
Klein, S. R., & Hobai, I. A. (2023). Semaglutide, delayed gastric emptying, and intraoperative pulmonary aspiration: a case report. Canadian Journal of Anesthesia/Journal Canadien d’anesthésie, 70(8), 1394–1396. https://doi.org/10.1007/s12630-023-02440-3
Makino, H., Tanaka, A., Asakura, K., Koezuka, R., Tochiya, M., Ohata, Y., Tamanaha, T., Son, C., Shimabara, Y., Fujita, T., Miyamoto, Y., Kobayashi, J., & Hosoda, K. (2019). Addition of low‐dose liraglutide to insulin therapy is useful for glycaemic control during the peri‐operative period: effect of glucagon‐like peptide‐1 receptor agonist therapy on glycaemic control in patients undergoing cardiac surgery ( GLOLIA study). Diabetic Medicine, 36(12), 1621–1628. https://doi.org/10.1111/dme.14084
Oprea, A. D., Ostapenko, L. J., Sweitzer, B., Selzer, A., Irizarry-Alvarado, J. M., Hurtado Andrade, M. D., Mendez, C. E., Kelley, K. D., Stewart, E., Fernandez Robles, C. R., Chadha, R. M., Camilleri, M., Mathur, R., Umpierrez, G. E., & Hepner, D. L. (2025). Perioperative management of patients taking glucagon-like peptide 1 receptor agonists: Society for Perioperative Assessment and Quality Improvement (SPAQI) multidisciplinary consensus statement. British Journal of Anaesthesia, 135(1), 48–78. https://doi.org/10.1016/j.bja.2025.04.001
Rajan, N., Duggan, E. W., Abdelmalak, B. B., Butz, S., Rodriguez, L. V., Vann, M. A., & Joshi, G. P. (2024). Society for Ambulatory Anesthesia Updated Consensus Statement on Perioperative Blood Glucose Management in Adult Patients With Diabetes Mellitus Undergoing Ambulatory Surgery. Anesthesia & Analgesia, 139(3), 459–477. https://doi.org/10.1213/ANE.0000000000006791
Sattar, N., Lee, M. M. Y., Kristensen, S. L., Branch, K. R. H., Del Prato, S., Khurmi, N. S., Lam, C. S. P., Lopes, R. D., McMurray, J. J. V, Pratley, R. E., Rosenstock, J., & Gerstein, H. C. (2021). Cardiovascular, mortality, and kidney outcomes with GLP-1 receptor agonists in patients with type 2 diabetes: a systematic review and meta-analysis of randomised trials. The Lancet Diabetes & Endocrinology, 9(10), 653–662. https://doi.org/10.1016/S2213-8587(21)00203-5
Shyangdan, D. S., Royle, P., Clar, C., Sharma, P., Waugh, N., & Snaith, A. (2011). Glucagon-like peptide analogues for type 2 diabetes mellitus. Cochrane Database of Systematic Reviews, 2013(7). https://doi.org/10.1002/14651858.CD006423.pub2
Sodhi, M., Rezaeianzadeh, R., Kezouh, A., & Etminan, M. (2023). Risk of Gastrointestinal Adverse Events Associated With Glucagon-Like Peptide-1 Receptor Agonists for Weight Loss. JAMA, 330(18), 1795. https://doi.org/10.1001/jama.2023.19574
Taha, M. B., Yahya, T., Satish, P., Laird, R., Agatston, A. S., Cainzos-Achirica, M., Patel, K. V., & Nasir, K. (2022). Glucagon-Like Peptide 1 Receptor Agonists: A Medication for Obesity Management. Current Atherosclerosis Reports, 24(8), 643–654. https://doi.org/10.1007/s11883-022-01041-7
Vilsboll, T., Christensen, M., Junker, A. E., Knop, F. K., & Gluud, L. L. (2012). Effects of glucagon-like peptide-1 receptor agonists on weight loss: systematic review and meta-analyses of randomised controlled trials. BMJ, 344(jan10 2), d7771–d7771. https://doi.org/10.1136/bmj.d7771
Copyright (c) 2025 Karol Grela, Aleksandra Grygorowicz, Klaudia Baran, Michał Ględa, Michał Szyszka, Weronika Radecka, Weronika Kozak, Agnieszka Szreiber, Karolina Nowacka, Kamil Jabłoński, Anna Woźniak, Kornelia Rynkiewicz
This work is licensed under a Creative Commons Attribution 4.0 International License.
All articles are published in open-access and licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0). Hence, authors retain copyright to the content of the articles.
CC BY 4.0 License allows content to be copied, adapted, displayed, distributed, re-published or otherwise re-used for any purpose including for adaptation and commercial use provided the content is attributed.
