Carole Ichai, MD, PhD, anesthesiologist and intensivist from the Université Côte d’Azur, Anesthesia and Critical Care Department, University of Nice, Nice, France, presented her findings at the 2026 French-speaking Diabetes Society Congress, March 31 to April 3, in Lyon, France, and outlined perioperative considerations associated with GLP-1 receptor agonists (RAs), which are prescribed for type 2 diabetes and obesity because of their gastrointestinal effects.

Originally developed to improve glycemic control by using the body’s natural “incretin effect,” GLP-1 RAs have shown broader metabolic effects, including reduced appetite and caloric intake. Their effects on gastrointestinal motility, particularly delayed gastric emptying, increase the aspiration risk during anesthesia.

Gastric Effects

GLP-1 RAs vary in their duration of action, with short- and long-acting formulations administered daily or weekly. These pharmacologic differences influence perioperative management.

Recent evidence shows that GLP-1 RAs increase residual gastric volume, increasing the risk for aspiration during perioperative management. Several meta-analyses published since 2023 supported this association.

This effect occurs with both short- and long-acting agents, although it appears to be more pronounced with long-acting formulations. This effect may persist even after treatment discontinuation beyond 7 days, suggesting a slow recovery of gastric emptying.

Factors that may further delay gastric emptying include:

• Higher doses, suggesting a dose-dependent effect
• The treatment initiation phase during dose escalation
• Interindividual variability

In contrast, long-acting agents may show reduced effects over time, consistent with tachyphylaxis, with gradual normalization of gastric emptying after several weeks of treatment.

Aspiration Risk

Although increased residual gastric volume is well documented, its clinical relevance remains uncertain. No direct relationship has been established between elevated gastric volume and pulmonary aspiration.

Aspiration remains rare in modern anesthesia, with an estimated incidence of 0.05%-0.20%. Most recent meta-analyses do not show an increased risk for aspiration in patients receiving GLP-1 RAs, despite a higher gastric volume.

Some analyses indicate a possible increase in risk, although the evidence remains limited and study methods vary considerably. The rarity of the event reduces the statistical power, making it difficult to draw definitive conclusions.

Ultrasound Role

Gastric ultrasonography is emerging as a valuable tool in perioperative care. It is noninvasive, accessible, and allows the assessment of gastric content before surgery.

This approach enables immediate adaptation of anesthetic strategies, including rapid sequence intubation and additional precautions.

Treatment Pause

However, the issue of preoperative discontinuation remains unresolved. Initial recommendations suggested:

• A 24-hour discontinuation for daily formulations
• Several days of discontinuation for weekly formulations

These recommendations are currently under review.

When GLP-1 RAs are discontinued, available data show the following:

• No clear relationship between the duration of discontinuation and reduction in residual gastric volume
• Slow stabilization of gastric volume, which may take several weeks
• No evidence of clinical benefit in reducing aspiration risk

Conversely, discontinuation is associated with the following:

• Glycemic imbalance
• Loss of cardiovascular and renal benefits
• Increased complexity in diabetes management

Fasting Rules

Current evidence does not support the extension of preoperative fasting. Prolonged fasting does not improve gastric emptying and may lead to dehydration, nausea, and anxiety.

Standard fasting guidelines should be followed, unless gastroparesis is suspected.

Risk Strategy

Recent recommendations favor an individualized approach based on risk assessment. Beyond treatment-related factors such as dose and initiation phase, clinicians should assess patient-specific factors, including:

• Gastrointestinal symptoms suggesting gastroparesis
• Comorbidities such as diabetic neuropathy
• Concomitant treatments, particularly opioids, slow gastric emptying

The recommendations published in 2025 by the French Society of Anesthesia and Intensive Care and the French-speaking Diabetes Society follow the same approach. These recommendations do not recommend discontinuing long-acting GLP-1 RAs within 7 days before surgery in low-risk patients.

In cases of uncertainty, gastric ultrasound may be considered, and anesthetic precautions may include:

• Preferential use of locoregional anesthesia
• Rapid sequence induction
• Use of fast-acting neuromuscular blocking agents

In conclusion, a pragmatic, individualized, and multidisciplinary approach involving anesthesiologists and diabetologists is the most proper strategy for balancing anesthetic safety with therapeutic management.

This story was translated from Univadis France, part of the Medscape Professional Network.