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
Association of Anaesthetists and partner… · 2025 · United Kingdom
Source and licence
- Authors
- Kariem El‐Boghdadly, Jugdeep Dhesi, Philippa Fabb et al.
- Title
- 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
- Journal
- Anaesthesia, 2025
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC11885194
Licence statement of the original publication
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Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
Glucagon‐like peptide‐1 receptor and glucose‐dependent insulinotropic polypeptide receptor agonists
- The risk of pulmonary aspiration and mitigation strategies should be discussed with the patient using a shared decision‐making approach. Patients should continue to take glucagon‐like peptide‐1 receptor agonists throughout the peri‐operative period. Patients and clinicians should adhere to recommended fasting guidelines. Upper gastrointestinal symptoms alone should not be used to determine gastric content. Regional anaesthesia should be considered as the primary anaesthetic technique, if appropriate. Point‐of‐care gastric ultrasound should be considered before induction of anaesthesia to facilitate risk stratification, if appropriate. Individualised pulmonary aspiration risk assessment should be completed, accounting for drug, patient and procedural factors. Anaesthesia and airway management should aim to reduce the risk of pulmonary aspiration on induction of anaesthesia, during maintenance and after emergence of anaesthesia. This could include: administering prokinetics; using a tracheal tube; modified rapid sequence intubation (with or without cricoid force, depending on local practice); head‐up position for induction of anaesthesia; potential use of gastric tubes to empty the stomach before induction of anaesthesia and tracheal extubation; and awake tracheal extubation.
- The risk of pulmonary aspiration and mitigation strategies should be discussed with the patient using a shared decision‐making approach.
- Patients should continue to take glucagon‐like peptide‐1 receptor agonists throughout the peri‐operative period.
- Patients and clinicians should adhere to recommended fasting guidelines.
- Upper gastrointestinal symptoms alone should not be used to determine gastric content.
- Regional anaesthesia should be considered as the primary anaesthetic technique, if appropriate.
- Point‐of‐care gastric ultrasound should be considered before induction of anaesthesia to facilitate risk stratification, if appropriate.
- Individualised pulmonary aspiration risk assessment should be completed, accounting for drug, patient and procedural factors.
- Anaesthesia and airway management should aim to reduce the risk of pulmonary aspiration on induction of anaesthesia, during maintenance and after emergence of anaesthesia. This could include: administering prokinetics; using a tracheal tube; modified rapid sequence intubation (with or without cricoid force, depending on local practice); head‐up position for induction of anaesthesia; potential use of gastric tubes to empty the stomach before induction of anaesthesia and tracheal extubation; and awake tracheal extubation.
Sodium‐glucose cotransporter‐2 inhibitors
- The risk of peri‐operative ketoacidosis and mitigation strategies should be discussed with the patient using a shared decision‐making approach. Sodium‐glucose cotransporter‐2 inhibitors should be omitted the day before and the day of a procedure. Patients and clinicians should adhere to recommended fasting guidelines and avoid prolonged starvation times. For patients discharged from hospital on the day of surgery, sodium‐glucose cotransporter‐2 inhibitors should be restarted once eating and drinking normally (usually 24–48 h after surgery). For patients staying in hospital after surgery, consider restarting sodium‐glucose cotransporter‐2 inhibitors once eating and drinking normally and capillary ketones are < 0.6 mmol.l‐1. For patients diagnosed with diabetes mellitus on a very low energy/liver reduction diet for the purposes of surgery, sodium‐glucose cotransporter‐2 inhibitors should be stopped at commencement of the diet, and adjust diabetes mellitus treatment as necessary. Written sick‐day rules should be provided to patients at pre‐operative assessment and at discharge.
- The risk of peri‐operative ketoacidosis and mitigation strategies should be discussed with the patient using a shared decision‐making approach.
- Sodium‐glucose cotransporter‐2 inhibitors should be omitted the day before and the day of a procedure.
- Patients and clinicians should adhere to recommended fasting guidelines and avoid prolonged starvation times.
- For patients discharged from hospital on the day of surgery, sodium‐glucose cotransporter‐2 inhibitors should be restarted once eating and drinking normally (usually 24–48 h after surgery).
- For patients staying in hospital after surgery, consider restarting sodium‐glucose cotransporter‐2 inhibitors once eating and drinking normally and capillary ketones are < 0.6 mmol.l‐1.
- For patients diagnosed with diabetes mellitus on a very low energy/liver reduction diet for the purposes of surgery, sodium‐glucose cotransporter‐2 inhibitors should be stopped at commencement of the diet, and adjust diabetes mellitus treatment as necessary.
- Written sick‐day rules should be provided to patients at pre‐operative assessment and at discharge.
Abstract
Introduction: Glucagon‐like peptide‐1 receptor agonists, dual glucose‐dependent insulinotropic peptide receptor agonists and sodium‐glucose cotransporter‐2 inhibitors are used increasingly in patients receiving peri‐operative care. These drugs may be associated with risks of peri‐operative pulmonary aspiration or euglycaemic ketoacidosis. We produced a consensus statement for the peri‐operative management of adults taking these drugs.
Methods: This multidisciplinary consensus statement included surgeons, anaesthetists, physicians, pharmacists and people with lived experience relevant to these guidelines. Following the directed literature review, a three‐round modified Delphi process was conducted to generate and ratify recommendations.
Results: Patients taking glucagon‐like peptide‐1 receptor agonists and dual glucose‐dependent insulinotropic peptide receptor agonists should: continue these drugs before surgery; have full risk assessment and stratification; and receive peri‐operative techniques that may mitigate risk of pulmonary aspiration before, during and after sedation or general anaesthesia. Patients taking sodium‐glucose cotransporter‐2 inhibitors should omit them the day before and the day of a procedure. All patients should have risks and mitigation strategies discussed with a shared decision‐making approach.
Discussion: Until more evidence becomes available, this pragmatic, multidisciplinary consensus statement aims to support shared decision‐making and improve safety for patients taking glucagon‐like peptide‐1 receptor agonists, dual glucose‐dependent insulinotropic peptide receptor agonists and sodium‐glucose cotransporter‐2 inhibitors during the peri‐operative period.
Contents of the original publication
The section headings of the original.
- Introduction
- Methods
- Glucagon‐like peptide‐1 receptor and glucose‐dependent insulinotropic polypeptide receptor agonists
- Sodium‐glucose cotransporter‐2 inhibitors
- Discussion
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