GLP-1 agonists and anesthesia: hold or continue?

The guidance reversed. ASA said hold in 2023; the 2024 multisociety guidance says most patients should continue — and explains why the hold never made pharmacologic sense.

Reviewed and updated August 2026 · Written by Anastasia Jackson, DNAP, CRNA

Every clinical claim on this page is cited to its source below. How we source clinical content — including the corrections we have made and why.

This is one of the few perioperative questions where the guidance genuinely reversed inside eighteen months, and a great deal of what is still circulating — including printed pre-op instructions — reflects the older position.

What changed, and when

The 2024 document was produced by the ASA together with the American Gastroenterological Association, the American Society for Metabolic and Bariatric Surgery, the International Society of Perioperative Care of Patients with Obesity, and the Society of American Gastrointestinal and Endoscopic Surgeons.^2,3 It describes itself as guidance rather than an evidence-based guideline, built on pharmacology and clinical experience, and centered on shared decision-making.²

Why the hold was abandoned

The pharmacology never supported it

Gastric emptying also tends to normalize as patients move from dose escalation onto a stable maintenance dose,⁴ which is why the risk stratification in the newer guidance turns on where the patient is in their treatment rather than on whether they took a dose.

The costs of holding are real

The multisociety guidance asks clinicians to weigh the risk of delayed emptying against the risk of stopping the drug for the condition it is treating, and notes that bridging off a GLP-1 agonist is resource intensive, may be cost or insurance prohibitive, and risks adverse effects including loss of glycemic control and hypoglycemia.³

Who is actually higher risk

Gastric ultrasound: useful, and not universally available

Point-of-care gastric ultrasound is the tool both documents reach for when there is clinical concern about retained contents on the day of the procedure. Both also flag its practical limits: it depends on institutional resources, carries interuser variability, and may require credentialing.²

The underlying data justify the concern it is used to resolve. Studies using endoscopy and gastric ultrasound have repeatedly found residual gastric contents in patients on GLP-1 receptor agonists after conventional fasting, including in volunteers without obesity recently started on semaglutide.^6,7 A large analysis of residual gastric content before anesthesia was published in JAMA Surgery in 2024,⁸ and a meta-analysis has quantified the magnitude of the emptying delay.⁹

What none of that establishes is a matching rate of clinical aspiration. Case reports exist — including intraoperative pulmonary aspiration attributed to semaglutide-related delayed emptying¹ — but large observational series have not shown a major increase in clinical aspiration in elective surgery. The current guidance reflects both facts at once: the physiology is real, and the event rate is low.

Where the societies still disagree

This is not fully settled, and knowing which document your institution follows matters.

• Gastrointestinal endoscopy societies have been slower to move. ASGE clinical guidance has continued to recommend withholding weekly agents for at least one week before procedures requiring anesthesia, with preoperative gastric ultrasound where the interval is shorter.¹⁰
• SPAQI published its own multidisciplinary consensus statement in the British Journal of Anaesthesia in 2025.¹¹
• UK practice has its own document — a multidisciplinary consensus statement from the Association of Anaesthetists and colleagues covering GLP-1 agonists, GIP agonists and SGLT-2 inhibitors together.¹²
• Surveys of practicing anesthesiologists continue to show variable adoption and residual disagreement with the guidance.¹³

Published comparisons of these documents note that recommendations vary significantly on both medication management and fasting protocols.¹⁴ If your unit’s pre-op instruction sheet still says hold, that is not necessarily an error — but it should be a decision rather than an artifact.

The practical reading

• Ask where the patient is in their treatment — escalating or stable, what dose, weekly or daily, last dose when.
• Ask about GI symptoms today, not in general. This is the question that changes the plan.
• Higher risk gets a 24-hour liquid diet, not a cancelled case.
• Scan if you are concerned and able. A gastric ultrasound answers the question that the medication history only estimates.
• Adjust the anesthetic rather than the schedule where possible — rapid sequence induction, or a technique that does not require an unprotected airway.
• Restart when the patient is eating normally. Coordinate with the prescriber, particularly if the interruption ran long enough to require re-titration.

Frequently asked questions

Do I need to stop Ozempic or Mounjaro before surgery?

Under the October 2024 multisociety guidance, most patients should continue their GLP-1 receptor agonist before elective surgery.³ This reversed the 2023 ASA guidance, which recommended holding daily formulations on the day of surgery and weekly formulations for one week.¹ Patients at higher risk of delayed gastric emptying are advised to take a liquid diet for 24 hours before the procedure instead.³

Why did the recommendation change?

Partly pharmacology and partly consequences. Holding a single dose does not normalize gastric emptying — that would require roughly five half-lives, about five weeks for weekly semaglutide.⁴ And the costs of holding are substantial: loss of glycemic control, rescheduling burden, and cost or insurance barriers.³ The newer guidance replaces a blanket hold with risk stratification.

Will my surgery be cancelled because I take a GLP-1?

It should not be, unless you have active gastrointestinal symptoms on the day — nausea, vomiting, abdominal pain or distension. The 2024 guidance specifies that delays and cancellations should be considered only in that situation.³

Who is at higher risk of a full stomach on a GLP-1?

Patients still escalating their dose rather than on a stable maintenance dose, those on higher doses, those on weekly rather than daily formulations, and those with other causes of delayed gastric emptying such as long-standing diabetes or Parkinson’s disease.^3,5

Is the aspiration risk from GLP-1 drugs real or overblown?

Both things are true. Studies using endoscopy and gastric ultrasound consistently find residual gastric contents after standard fasting in patients on these drugs,^6,7,8 and case reports of aspiration exist.¹ But large observational series have not demonstrated a major increase in clinical aspiration during elective surgery. The current guidance is written to hold both findings at once.

What is gastric ultrasound and will I get one?

A bedside ultrasound of the stomach that estimates residual contents. Both documents recommend it where there is clinical concern on the day of the procedure, and both note that availability depends on institutional resources, operator training and credentialing.^1,2 Not every unit can offer it.

References

1. Joshi GP, Abdelmalak BB, Weigel WA, et al. American Society of Anesthesiologists consensus-based guidance on preoperative management of patients (adults and children) on glucagon-like peptide-1 (GLP-1) receptor agonists. ASA, June 2023. Includes the Klein & Hobai case report of semaglutide, delayed gastric emptying and intraoperative pulmonary aspiration.
2. Multisociety clinical practice guidance for the safe use of glucagon-like peptide-1 receptor agonists in the perioperative period. Clin Gastroenterol Hepatol. doi:10.1016/j.cgh.2024.10.003. PMID 39480373. Also published in Surg Obes Relat Dis. 2024;20(12):1183–1186.
3. New multi-society GLP-1 clinical practice guidance released. American Society of Anesthesiologists news release, 29 October 2024. Continuation for most patients; 24-hour liquid diet for highest-risk; delay only for GI symptoms; the overweight and obesity bias statement; approximately one in eight US adults using GLP-1 drugs.
4. How should GLP-1 receptor agonists be managed in the perioperative period? Commentary noting that five half-lives — about five weeks for weekly semaglutide — would be required to normalize gastric emptying, and that emptying often normalizes on a stable dose.
5. Idris I, et al. Multi-society consensus guidance on handling of GLP-1 therapy prior to general anaesthesia. Diabetes Obes Metab Now. 2024. doi:10.1002/doi2.70009. Summarizes the risk factors: escalation phase, higher dose, weekly versus daily formulation.
6. Silveira SQ, da Silva LM, de Campos Vieira Abib A, et al. Relationship between perioperative semaglutide use and residual gastric content: a retrospective analysis of patients undergoing elective upper endoscopy. J Clin Anesth. 2023;87:111091.
7. Sherwin M, Hamburger J, Katz D, et al. Influence of semaglutide use on the presence of residual gastric solids on gastric ultrasound: a prospective observational study in volunteers without obesity recently started on semaglutide. Can J Anaesth. 2023;70:1300–1306.
8. Sen S, Potnuru PP, Hernandez N, et al. Glucagon-like peptide-1 receptor agonist use and residual gastric content before anesthesia. JAMA Surg. 2024;159(6):660–667.
9. Hiramoto B, McCarty T, Lodhia N, et al. Quantified metrics of gastric emptying delay by glucagon-like peptide-1 agonists: a systematic review and meta-analysis with insights for periprocedural management. Am J Gastroenterol. 2024;119(6):1126–1140.
10. ASGE clinical guidance, 2025, recommending withholding weekly GLP-1 agents for at least one week before procedures requiring anesthesia, with preoperative gastric ultrasound for shorter intervals.
11. Perioperative management of patients taking glucagon-like peptide 1 receptor agonists: Society for Perioperative Assessment and Quality Improvement (SPAQI) multidisciplinary consensus statement. Br J Anaesth. 2025. doi:10.1016/j.bja.2025.02.014
12. El-Boghdadly K, Dhesi J, Fabb P, et al. 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. 2025;80:412–424.
13. Boudreau B, Watson NC. Anesthesiologists’ perspectives on GLP-1 receptor agonists in elective surgeries: a qualitative survey analysis of national data. Cureus. 2025;17(11):e95986. doi:10.7759/cureus.95986
14. Chang MG, Bittner EA. Comparison of societal guidance on perioperative management of glucagon-like peptide-1 receptor agonists: implications for clinical practice and future investigations.