GLP-1 agonists in anaesthetic practice - a review of clinical data and recommendations
DOI:
https://doi.org/10.12775/JEHS.2025.83.61812Keywords
glukagon-like peptide-1 agonists, gastric emptying, aspiration, anaesthesia, perioperative managementAbstract
Abstract
Introduction: Glucagon-like peptide-1 receptor agonists (GLP-1 RA) are a group of drugs originally used for the treatment of type 2 diabetes and now also for obesity and off-label indications. With the increasing popularity of the use of these substances, the likelihood of encountering such a patient in the operating theatre is increasing, creating new challenges for anaesthetic practice.
Purpose: The aim of the following paper is to review current clinical data on patients using GLP-1 agonists in perioperative care and to provide recommendations from scientific societies for the management of these patients.
Materials and research methods: The article is based on an analysis of research available on PubMed and Google Scholar. A literature review was conducted using the following keywords and medical subject headings: glucagon-like peptide-1 agonists; GLP-1 RA; perioperative period; gastric emptying; preoperative management; aspiration. The analysis included clinical trials, systematic reviews and expert consensus statements.
Results: GLP-1 analogues show a number of beneficial metabolic, cardioprotective and nephroprotective effects, which may improve the overall health of patients. At the same time, these drugs, by delaying gastric emptying, increase the risk of regurgitation and pulmonary aspiration during induction of anaesthesia.
Conclusion: Despite the growing population of patients using GLP-1 agonists, there are still no detailed reports on the basis of which guidelines for ideal management can be developed. Therefore, despite the existence of general recommendations from societies, special caution and an individual approach when working with such patients is advisable.
References
Jensterle, M., Rizzo, M., Haluzík, M., & Janež, A. (2022). Efficacy of GLP-1 RA Approved for Weight Management in Patients With or Without Diabetes: A Narrative Review. Advances in therapy, 39(6), 2452–2467. https://doi.org/10.1007/s12325-022-02153-x
Batista, A. F., Forny-Germano, L., Clarke, J. R., Lyra E Silva, N. M., Brito-Moreira, J., Boehnke, S. E., Winterborn, A., Coe, B. C., Lablans, A., Vital, J. F., Marques, S. A., Martinez, A. M., Gralle, M., Holscher, C., Klein, W. L., Houzel, J. C., Ferreira, S. T., Munoz, D. P., & De Felice, F. G. (2018). The diabetes drug liraglutide reverses cognitive impairment in mice and attenuates insulin receptor and synaptic pathology in a non-human primate model of Alzheimer's disease. The Journal of pathology, 245(1), 85–100.
https://doi.org/10.1002/path.5056
Albuquerque, M. B., Nunes, L. E. D. B., Oliveira Maldonado, J. V., Melo Ferreira, D. G., Margato, M. M., Rabelo, L. V., Valença, M. M., & Oliveira Cordeiro, L. H. (2025). GLP-1 receptor agonists for Parkinson's disease: An updated meta-analysis. Parkinsonism & related disorders, 130, 107220. https://doi.org/10.1016/j.parkreldis.2024.107220
Watanabe, J. H., Kwon, J., Nan, B., & Reikes, A. (2024). Trends in glucagon-like peptide 1 receptor agonist use, 2014 to 2022. Journal of the American Pharmacists Association : JAPhA, 64(1), 133–138.
https://doi.org/10.1016/j.japh.2023.10.002
Mahase E. (2024). GLP-1 agonists: US sees 700% increase over four years in number of patients without diabetes starting treatment. BMJ (Clinical research ed.), 386, q1645.
https://doi.org/10.1136/bmj.q1645
Hulst, A. H., Polderman, J. A. W., Siegelaar, S. E., van Raalte, D. H., DeVries, J. H., Preckel, B., & Hermanides, J. (2021). Preoperative considerations of new long-acting glucagon-like peptide-1 receptor agonists in diabetes mellitus. British journal of anaesthesia, 126(3), 567–571.
https://doi.org/10.1016/j.bja.2020.10.023
Nauck, M. A., & Meier, J. J. (2016). The incretin effect in healthy individuals and those with type 2 diabetes: physiology, pathophysiology, and response to therapeutic interventions. The lancet. Diabetes & endocrinology, 4(6), 525–536. https://doi.org/10.1016/S2213-8587(15)00482-9
Campbell, J. E., & Drucker, D. J. (2013). Pharmacology, physiology, and mechanisms of incretin hormone action. Cell metabolism, 17(6), 819–837. https://doi.org/10.1016/j.cmet.2013.04.008
Zhao, X., Wang, M., Wen, Z., Lu, Z., Cui, L., Fu, C., Xue, H., Liu, Y., & Zhang, Y. (2021). GLP-1 Receptor Agonists: Beyond Their Pancreatic Effects. Frontiers in endocrinology, 12, 721135.
https://doi.org/10.3389/fendo.2021.721135
Anderson J. The Pharmacokinetic Properties of Glucagon-like Peptide-1 Receptor Agonists and Their Mode and Mechanism of Action in Patients with Type 2 Diabetes. J Fam Pract. 2018;67(6 suppl):S8-S13.
Clements, J.N., Isaacs, D., Hartman, R.E. et al. Pharmacokinetics and Clinical Implications of Oral Semaglutide for Type 2 Diabetes Mellitus. Clin Pharmacokinet 60, 153–163 (2021).
https://doi.org/10.1007/s40262-020-00951-6
Meier J. J. (2012). GLP-1 receptor agonists for individualized treatment of type 2 diabetes mellitus. Nature reviews. Endocrinology, 8(12), 728–742. https://doi.org/10.1038/nrendo.2012.140
Latif W, Lambrinos KJ, Patel P, Rodriguez R. Compare and Contrast the Glucagon-Like Peptide-1 Receptor Agonists (GLP1RAs). In: StatPearls. Treasure Island (FL): StatPearls Publishing; February 25, 2024.
Nauck, M. A., Quast, D. R., Wefers, J., & Pfeiffer, A. F. H. (2021). The evolving story of incretins (GIP and GLP-1) in metabolic and cardiovascular disease: A pathophysiological update. Diabetes, obesity & metabolism, 23 Suppl 3, 5–29. https://doi.org/10.1111/dom.14496
Marso, S. P., Daniels, G. H., Brown-Frandsen, K., Kristensen, P., Mann, J. F., Nauck, M. A., Nissen, S. E., Pocock, S., Poulter, N. R., Ravn, L. S., Steinberg, W. M., Stockner, M., Zinman, B., Bergenstal, R. M., Buse, J. B., LEADER Steering Committee, & LEADER Trial Investigators (2016). Liraglutide and Cardiovascular Outcomes in Type 2 Diabetes. The New England journal of medicine, 375(4), 311–322.
https://doi.org/10.1056/NEJMoa1603827
Gerstein, H. C., Colhoun, H. M., Dagenais, G. R., Diaz, R., Lakshmanan, M., Pais, P., Probstfield, J., Riesmeyer, J. S., Riddle, M. C., Rydén, L., Xavier, D., Atisso, C. M., Dyal, L., Hall, S., Rao-Melacini, P., Wong, G., Avezum, A., Basile, J., Chung, N., Conget, I., REWIND Investigators (2019). Dulaglutide and cardiovascular outcomes in type 2 diabetes (REWIND): a double-blind, randomised placebo-controlled trial. Lancet (London, England), 394(10193), 121–130. https://doi.org/10.1016/S0140-6736(19)31149-3
Marso, S. P., Bain, S. C., Consoli, A., Eliaschewitz, F. G., Jódar, E., Leiter, L. A., Lingvay, I., Rosenstock, J., Seufert, J., Warren, M. L., Woo, V., Hansen, O., Holst, A. G., Pettersson, J., Vilsbøll, T., & SUSTAIN-6 Investigators (2016). Semaglutide and Cardiovascular Outcomes in Patients with Type 2 Diabetes. The New England journal of medicine, 375(19), 1834–1844.
https://doi.org/10.1056/NEJMoa1607141
Horowitz, M., Rayner, C. K., Marathe, C. S., Wu, T., & Jones, K. L. (2020). Glucagon-like peptide-1 receptor agonists and the appropriate measurement of gastric emptying. Diabetes, obesity & metabolism, 22(12), 2504–2506. https://doi.org/10.1111/dom.14166
Aldawsari, M., Almadani, F. A., Almuhammadi, N., Algabsani, S., Alamro, Y., & Aldhwayan, M. (2023). The Efficacy of GLP-1 Analogues on Appetite Parameters, Gastric Emptying, Food Preference and Taste Among Adults with Obesity: Systematic Review of Randomized Controlled Trials. Diabetes, metabolic syndrome and obesity:targets and therapy, 16, 575–595.
https://doi.org/10.2147/DMSO.S387116
Nakatani, Y., Maeda, M., Matsumura, M., Shimizu, R., Banba, N., Aso, Y., Yasu, T., & Harasawa, H. (2017). Effect of GLP-1 receptor agonist on gastrointestinal tract motility and residue rates as evaluated by capsule endoscopy. Diabetes & metabolism, 43(5), 430–437.
https://doi.org/10.1016/j.diabet.2017.05.009
Marathe, C. S., Rayner, C. K., Jones, K. L., & Horowitz, M. (2013). Glucagon-like peptides 1 and 2 in health and disease: a review. Peptides, 44, 75–86. https://doi.org/10.1016/j.peptides.2013.01.014
Kabahizi, A., Wallace, B., Lieu, L., Chau, D., Dong, Y., Hwang, E. S., & Williams, K. W. (2022). Glucagon-like peptide-1 (GLP-1) signalling in the brain: From neural circuits and metabolism to therapeutics. British journal of pharmacology, 179(4), 600–624.
https://doi.org/10.1111/bph.15682
Holmes, G. M., Browning, K. N., Tong, M., Qualls-Creekmore, E., & Travagli, R. A. (2009). Vagally mediated effects of glucagon-like peptide 1: in vitro and in vivo gastric actions. The Journal of physiology, 587(Pt 19), 4749–4759. https://doi.org/10.1113/jphysiol.2009.175067
Schwartz T. W. (1983). Pancreatic polypeptide: a unique model for vagal control of endocrine systems. Journal of the autonomic nervous system, 9(1), 99–111. https://doi.org/10.1016/0165-1838(83)90134-0
Stark, J. E., Cole, J. L., Ghazarian, R. N., & Klass, M. J. (2022). Impact of Glucagon-Like Peptide-1 Receptor Agonists (GLP-1RA) on Food Content During Esophagogastroduodenoscopy (EGD). The Annals of pharmacotherapy, 56(8), 922–926.
https://doi.org/10.1177/10600280211055804
Silveira, S. Q., da Silva, L. M., de Campos Vieira Abib, A., de Moura, D. T. H., de Moura, E. G. H., Santos, L. B., Ho, A. M., Nersessian, R. S. F., Lima, F. L. M., Silva, M. V., & Mizubuti, G. B. (2023). Relationship between perioperative semaglutide use and residual gastric content: A retrospective analysis of patients undergoing elective upper endoscopy. Journal of clinical anesthesia, 87, 111091. https://doi.org/10.1016/j.jclinane.2023.111091
Wu, F., Smith, M. R., Mueller, A. L., Klapman, S. A., Everett, L. L., Houle, T., Kuo, B., & Hobai, I. A. (2024). Association of glucagon-like peptide receptor 1 agonist therapy with the presence of gastric contents in fasting patients undergoing endoscopy under anesthesia care: a historical cohort study. 71(7), 958–966. https://doi.org/10.1007/s12630-024-02719-z
Sherwin, M., Hamburger, J., Katz, D., & DeMaria, S., Jr (2023). 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. Canadian journal of anaesthesia, 70(8), 1300–1306. https://doi.org/10.1007/s12630-023-02549-5
Sen, S., Potnuru, P. P., Hernandez, N., Goehl, C., Praestholm, C., Sridhar, S., & Nwokolo, O. O. (2024). Glucagon-Like Peptide-1 Receptor Agonist Use and Residual Gastric Content Before Anesthesia. JAMA surgery, 159(6), 660–667. https://doi.org/10.1001/jamasurg.2024.0111
Umapathysivam, M. M., Lee, M. Y., Jones, K. L., Annink, C. E., Cousins, C. E., Trahair, L. G., Rayner, C. K., Chapman, M. J., Nauck, M. A., Horowitz, M., & Deane, A. M. (2014). Comparative effects of prolonged and intermittent stimulation of the glucagon-like peptide 1 receptor on gastric emptying and glycemia. Diabetes, 63(2), 785–790.
https://doi.org/10.2337/db13-0893
Linnebjerg, H., Park, S., Kothare, P. A., Trautmann, M. E., Mace, K., Fineman, M., Wilding, I., Nauck, M., & Horowitz, M. (2008). Effect of exenatide on gastric emptying and relationship to postprandial glycemia in type 2 diabetes. Regulatory peptides, 151(1-3), 123–129.
https://doi.org/10.1016/j.regpep.2008.07.003
Kuwata, H., Yabe, D., Murotani, K., Fujiwara, Y., Haraguchi, T., Kubota, S., Kubota-Okamoto, S., Usui, R., Ishitobi, M., Yamazaki, Y., Hamamoto, Y., Kurose, T., Seino, Y., Yamada, Y., & Seino, Y. (2021). Effects of glucagon-like peptide-1 receptor agonists on secretions of insulin and glucagon and gastric emptying in Japanese individuals with type 2 diabetes: A prospective, observational study. Journal of diabetes investigation, 12(12), 2162–2171.
https://doi.org/10.1111/jdi.13598
Meier, J. J., Rosenstock, J., Hincelin-Méry, A., Roy-Duval, C., Delfolie, A., Coester, H. V., Menge, B. A., Forst, T., & Kapitza, C. (2015). Contrasting Effects of Lixisenatide and Liraglutide on Postprandial Glycemic Control, Gastric Emptying, and Safety Parameters in Patients With Type 2 Diabetes on Optimized Insulin Glargine With or Without Metformin: A Randomized, Open-Label Trial. Diabetes care, 38(7), 1263–1273.
https://doi.org/10.2337/dc14-1984
Flint, A., Raben, A., Ersbøll, A. K., Holst, J. J., & Astrup, A. (2001). The effect of physiological levels of glucagon-like peptide-1 on appetite, gastric emptying, energy and substrate metabolism in obesity. International journal of obesity and related metabolic disorders : journal of the International Association for the Study of Obesity, 25(6), 781–792.
https://doi.org/10.1038/sj.ijo.0801627
van Can, J., Sloth, B., Jensen, C. B., Flint, A., Blaak, E. E., & Saris, W. H. (2014). Effects of the once-daily GLP-1 analog liraglutide on gastric emptying, glycemic parameters, appetite and energy metabolism in obese, non-diabetic adults. International journal of obesity (2005), 38(6), 784–793. https://doi.org/10.1038/ijo.2013.162
Saxena, A. R., Banerjee, A., Corbin, K. D., Parsons, S. A., & Smith, S. R. (2021). Energy intake as a short-term biomarker for weight loss in adults with obesity receiving liraglutide: A randomized trial. Obesity science & practice, 7(3), 281–290. https://doi.org/10.1002/osp4.486
Kobori, T., Onishi, Y., Yoshida, Y., Tahara, T., Kikuchi, T., Kubota, T., Iwamoto, M., Sawada, T., Kobayashi, R., Fujiwara, H., & Kasuga, M. (2023). Association of glucagon-like peptide-1 receptor agonist treatment with gastric residue in an esophagogastroduodenoscopy. Journal of diabetes investigation, 14(6), 767–773. https://doi.org/10.1111/jdi.14005
Nersessian, R. S. F., da Silva, L. M., Carvalho, M. A. S., Silveira, S. Q., Abib, A. C. V., Bellicieri, F. N., Lima, H. O., Ho, A. M., Anjos, G. S., & Mizubuti, G. B. (2024). Relationship between residual gastric content and peri-operative semaglutide use assessed by gastric ultrasound: a prospective observational study. Anaesthesia, 79(12), 1317–1324.
https://doi.org/10.1111/anae.16454
Nauck, M. A., Kemmeries, G., Holst, J. J., & Meier, J. J. (2011). Rapid tachyphylaxis of the glucagon-like peptide 1-induced deceleration of gastric emptying in humans. Diabetes, 60(5), 1561–1565.
https://doi.org/10.2337/db10-0474
Bettge, K., Kahle, M., Abd El Aziz, M. S., Meier, J. J., & Nauck, M. A. (2017). Occurrence of nausea, vomiting and diarrhoea reported as adverse events in clinical trials studying glucagon-like peptide-1 receptor agonists: A systematic analysis of published clinical trials. Diabetes, obesity & metabolism, 19(3), 336–347. https://doi.org/10.1111/dom.12824
Singh, S., Chang, H. Y., Richards, T. M., Weiner, J. P., Clark, J. M., & Segal, J. B. (2013). Glucagonlike peptide 1-based therapies and risk of hospitalization for acute pancreatitis in type 2 diabetes mellitus: a population-based matched case-control study. JAMA internal medicine, 173(7), 534–539. https://doi.org/10.1001/jamainternmed.2013.2720
Calvarysky, B., Dotan, I., Shepshelovich, D., Leader, A., & Cohen, T. D. (2024). Drug-Drug Interactions Between Glucagon-Like Peptide 1 Receptor Agonists and Oral Medications: A Systematic Review. Drug safety, 47(5), 439–451. https://doi.org/10.1007/s40264-023-01392-3
Weber, M., Siddarthan, I., & Mack, P. F. (2023). Clinically significant emesis in a patient taking a long-acting GLP-1 receptor agonist for weight loss. British journal of anaesthesia, 131(2), e37–e39.
https://doi.org/10.1016/j.bja.2023.05.005
Avraham, S. A., Hossein, J., Somri, F., Hawash, N., & Hochman, O. (2024). Pulmonary aspiration of gastric contents in two patients taking semaglutide for weight loss. Anaesthesia reports, 12(1), e12278.
https://doi.org/10.1002/anr3.12278
Gulak, M. A., & Murphy, P. (2023). Regurgitation under anesthesia in a fasted patient prescribed semaglutide for weight loss: a case report. Canadian journal of anaesthesia, 70(8), 1397–1400.
https://doi.org/10.1007/s12630-023-02521-3
Klein, S. R., & Hobai, I. A. (2023). Semaglutide, delayed gastric emptying, and intraoperative pulmonary aspiration: a case report. Canadian journal of anaesthesia, 70(8), 1394–1396.
https://doi.org/10.1007/s12630-023-02440-3
Fujino, E., Cobb, K. W., Schoenherr, J., Gouker, L., & Lund, E. (2023). Anesthesia Considerations for a Patient on Semaglutide and Delayed Gastric Emptying. Cureus, 15(7), e42153.
https://doi.org/10.7759/cureus.42153
Alkabbani, W., Suissa, K., Gu, K. D., Cromer, S. J., Paik, J. M., Bykov, K., Hobai, I., Thompson, C. C., Wexler, D. J., & Patorno, E. (2024). Glucagon-like peptide-1 receptor agonists before upper gastrointestinal endoscopy and risk of pulmonary aspiration or discontinuation of procedure: cohort study. BMJ (Clinical research ed.), 387, e080340.
https://doi.org/10.1136/bmj-2024-080340
Dhatariya, K., Levy, N., Russon, K., Patel, A., Frank, C., Mustafa, O., Newland-Jones, P., Rayman, G., Tinsley, S., & Dhesi, J. (2024). Perioperative use of glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter 2 inhibitors for diabetes mellitus. British journal of anaesthesia, 132(4), 639–643. https://doi.org/10.1016/j.bja.2023.12.015
Santos, L. B., Mizubuti, G. B., da Silva, L. M., Silveira, S. Q., Nersessian, R. S. F., Abib, A. C. V., Bellicieri, F. N., Lima, H. O., Ho, A. M., Dos Anjos, G. S., de Moura, D. T. H., de Moura, E. G. H., & Vieira, J. E. (2024). Effect of various perioperative semaglutide interruption intervals on residual gastric content assessed by esophagogastroduodenoscopy: A retrospective single center observational study. Journal of clinical anesthesia, 99, 111668. https://doi.org/10.1016/j.jclinane.2024.111668
Joshi GP, Abdelmalak BB, Weigel WA, Soriano SG, Harbell MW, Kuo CI, Stricker PA, Domino KB, American Society of Anesthesiologist (ASA) Task Force on Perioperative Fasting: American Society of Anesthesiologists consensus-based guidance on preoperative management of patients (adults and children) on glucagon-like peptide-1 (GLP-1) receptor agonists. June 29, 2023. available at: https://www.asahq.org/about-asa/newsroom/news-releases/2023/06/american-society-of-anesthesiologists-consensus-based-guidance-on-preoperative. Accessed August 20, 2023.
Beam WB, Guevara LRH. Are serious anaesthesia risks of semaglutide and other GLP-1 agonists under-recognized? Case reports of retained solid gastric contents in patients undergoing anaesthesia. APSF Newsletter. 2023;(38):69-71.
Brennan, M., Han, S. H., Ockerman, K., Mehta, S. D., Furnas, H. J., Heath, F., Mars, P., Klenke, A., & Sorice-Virk, S. C. (2025). Perioperative Practice Patterns of Anaesthesiologists Surrounding Glucagon-Like Peptide-1 (GLP-1) Agonist Medications. Turkish journal of anaesthesiology and reanimation, 53(2), 42–52. https://doi.org/10.4274/TJAR.2025.241653
Stubbs DJ, Levy N, Dhatariya K. The rationale and the strategies to achieve perioperative glycaemic control. BJA Educ 2017; 17: 185-93. https://doi.org/10.1093/bjaed/mkw071.
Frisch, A., Chandra, P., Smiley, D., Peng, L., Rizzo, M., Gatcliffe, C., Hudson, M., Mendoza, J., Johnson, R., Lin, E., & Umpierrez, G. E. (2010). Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery. Diabetes care, 33(8), 1783–1788.
https://doi.org/10.2337/dc10-0304
Sampson, M. J., Dozio, N., Ferguson, B., & Dhatariya, K. (2007). Total and excess bed occupancy by age, specialty and insulin use for nearly one million diabetes patients discharged from all English Acute Hospitals. Diabetes research and clinical practice, 77(1), 92–98.
https://doi.org/10.1016/j.diabres.2006.10.004
Milder, D. A., Milder, T. Y., Liang, S. S., & Kam, P. C. A. (2024). Glucagon-like peptide-1 receptor agonists: a narrative review of clinical pharmacology and implications for peri-operative practice. Anaesthesia, 79(7), 735–747. https://doi.org/10.1111/anae.16306
Ushakumari, D. S., & Sladen, R. N. (2024). ASA Consensus-based Guidance on Preoperative Management of Patients on Glucagon-like Peptide-1 Receptor Agonists. Anesthesiology, 140(2), 346–348.
https://doi.org/10.1097/ALN.0000000000004776
Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. (2017). Anesthesiology, 126(3), 376–393.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2025 Natalia Pokrywka, Marcelina Polak, Dawid Suwała, Paulina Hetnar, Milena Fortuna, Sebastian Kiper, Sławomir Toczek, Magdalena Tomala , Katarzyna Jastrowicz-Chęć, Klaudia Koryszko
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
The periodical offers access to content in the Open Access system under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0
Stats
Number of views and downloads: 192
Number of citations: 0
