Stopping GLP-1s Before Surgery: The ASA & Multi-Society Guidance Explained

The American Society of Anesthesiologists' 2023 consensus-based guidance on preoperative management of GLP-1 receptor agonists was significantly updated in October 2024. The original "hold for a week" rule no longer reflects current best practice for most patients. Here's what changed, who actually needs to hold their dose, and what to discuss with your surgeon and anesthesiologist.

If you're on Wegovy, Ozempic, Mounjaro, Zepbound, or any other GLP-1 receptor agonist and you have surgery scheduled, you've probably been told some version of "stop your medication a week before the procedure." That instruction comes from a specific document — the American Society of Anesthesiologists' (ASA) consensus-based guidance issued in June 2023. It made clinical sense at the time. It was also based on limited evidence and, after sixteen months of accumulated real-world data, was substantially revised.

This guide walks through both versions of the guidance, explains exactly what changed and why, breaks down what current best practice actually says for each common GLP-1 medication, and provides a clear list of what to discuss with your surgical and anesthesia teams.

Why GLP-1s Matter for Anesthesia at All

The concern is straightforward: GLP-1 receptor agonists slow gastric emptying. That's part of how they work — by keeping food in the stomach longer, they extend feelings of fullness and reduce appetite. The unintended consequence is that even after the standard preoperative fasting period (typically 8 hours for solids, 2 hours for clear liquids), some patients on GLP-1 therapy still have residual food and fluid in their stomachs.

Under general anesthesia or deep sedation, retained gastric contents can be regurgitated and aspirated into the lungs. Pulmonary aspiration of gastric contents is uncommon but potentially serious — it can cause aspiration pneumonitis, pneumonia, respiratory failure, and rare cases of death. The clinical question is how much extra risk GLP-1 therapy adds, and what to do about it.

The Original 2023 ASA Guidance

In June 2023, the American Society of Anesthesiologists released its first consensus-based guidance on preoperative management of patients on GLP-1 receptor agonists. The document was authored by Girish P. Joshi, M.D., FASA, and colleagues, and reflected the cautious early-phase response to a rapidly emerging signal.

The original recommendations were simple and strict:

This is the version of the guidance most patients have heard about, most surgeons learned about, and many telehealth platforms still cite when sending pre-surgical instructions. It was a precautionary response to an emerging safety signal, written before substantial clinical data had accumulated.

What Changed: The October 2024 Multi-Society Update

In October 2024, an updated guidance document was released — this time as a multi-society effort led by the ASA and joined by four other major medical organizations:

• American Society of Anesthesiologists (ASA) — led the effort
• American Gastroenterological Association (AGA)
• American Society for Metabolic and Bariatric Surgery (ASMBS)
• International Society of Perioperative Care of Patients with Obesity (ISPCOP)
• Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)

The update was published in Clinical Gastroenterology and Hepatology and other society journals. The framing shifted substantially. Rather than a blanket "hold for a week" recommendation, the update emphasizes individualized risk assessment, shared decision-making between patient and care team, and a layered set of precautions that allow most patients to continue their medication safely.

The headline change: most patients can continue their GLP-1 before surgery.

The 2024 Multi-Society Recommendations in Plain English

The current guidance organizes around three core ideas: identify high-risk patients, modify diet for those at higher risk, and adjust the anesthesia plan to manage residual aspiration risk.

Step 1: Identify Patients at Elevated Risk for Delayed Gastric Emptying

The 2024 guidance identifies several factors that mark a patient as higher-risk for residual gastric contents at the time of surgery:

Step 2: Adjust Preoperative Diet for Higher-Risk Patients

For patients in the elevated-risk group, the multi-society guidance recommends a clear liquid diet for 24 hours before surgery, on top of the standard preoperative fasting period. This is a significant change from the 2023 guidance, which simply held the medication. The 24-hour clear liquid window allows the stomach to empty even if the medication's slowing effect persists, without requiring patients to skip multiple weeks of effective therapy.

Clear liquids in this context include water, clear broths, plain tea or coffee without milk, clear juices (apple, grape — no pulp), Gatorade or similar electrolyte drinks, and plain gelatin. No solids, no dairy, no opaque liquids (smoothies, milk, juice with pulp). The standard 2-hour clear liquid cutoff before anesthesia still applies on top of this.

Step 3: Adjust the Anesthesia Plan

The third layer is the anesthesia team's responsibility. The guidance recommends:

• Rapid sequence induction for tracheal intubation in higher-risk patients undergoing general anesthesia. This technique minimizes the window during which an unprotected airway is exposed to potential regurgitation.
• Point-of-care gastric ultrasound for the highest-risk patients — a non-invasive bedside ultrasound that can directly visualize residual gastric contents and inform the anesthesia approach.
• Aspiration precautions throughout the perioperative period, including head-of-bed positioning and careful extubation technique.

When to Still Hold the Medication

The 2024 guidance preserves a role for holding GLP-1 therapy in specific circumstances:

Drug-by-Drug Reference

Combining the 2024 multi-society guidance with the underlying pharmacokinetics of each drug, here is the practical hold/continue logic for each commonly prescribed GLP-1 medication:

These are defaults. Your anesthesia team has the final say based on your individual risk factors, the specific procedure, and the clinical setting.

Where the 2023 vs 2024 Discrepancy Causes Real Confusion

Many patients are still being given the older 2023 instructions by their surgeon's office, their telehealth provider, or the GLP-1 clinic that prescribed their medication. There are a few reasons this happens:

• Knowledge lag. Most clinicians have not memorized the October 2024 update — many still cite the 2023 version because it was the more widely publicized initial guidance.
• Defensive medicine. The simpler "hold for a week" rule is easier to enforce and harder to be criticized for, even if it leads to more weight regain and disrupted glycemic control.
• Heterogeneous prescriber networks. Telehealth platforms vary widely in how aggressively they update perioperative instructions to reflect new guidance.

If you receive instructions to hold your GLP-1 for a full week before a routine procedure, it's reasonable to ask your anesthesiologist whether the updated 2024 multi-society guidance applies to your specific situation. Both approaches are clinically defensible. Continuing the medication with appropriate precautions reflects current best evidence; holding the medication entirely reflects the more conservative original guidance.

What Patients Should Discuss With Their Care Team

Whether the decision is to continue or hold, a clear conversation between you and your anesthesia, surgical, and prescribing teams is essential. Share the following information at your preoperative visit:

Your anesthesia team will use this information to decide whether you need a clear liquid diet ahead of the standard fast, whether to use rapid sequence induction, whether to perform a gastric ultrasound, and whether the procedure should proceed as planned or be modified.

What Happens If You Forget to Tell Them

Anesthesiologists routinely ask about all medications during their preoperative interview, but if a GLP-1 is missed and discovered intraoperatively or after a regurgitation event, the response depends on the circumstances. In an outpatient procedure with a relatively low aspiration risk, the case may proceed with additional vigilance. In a higher-risk procedure or if the patient has GI symptoms, the case may be postponed.

The simpler rule: tell every member of your care team — your surgeon, your anesthesiologist, your preoperative nurse — that you are on a GLP-1 medication. They cannot apply the right protocol if they don't know.

Special Situations

Endoscopy and colonoscopy

Upper endoscopy and colonoscopy are common procedures that have generated specific concern. The American Gastroenterological Association and other endoscopic societies have generally recommended an individualized approach. For routine colonoscopy with no upper GI procedure planned and standard bowel prep, most patients can continue their GLP-1 with the prep itself serving as effective gastric emptying. For upper endoscopy or combined procedures, clear liquid diet for 24 hours plus careful aspiration precautions is standard.

Bariatric surgery

Patients on GLP-1 therapy who are scheduled for bariatric surgery (sleeve gastrectomy, Roux-en-Y gastric bypass) are a special case. The American Society for Metabolic and Bariatric Surgery — a co-author of the 2024 multi-society guidance — has specific protocols for this population. The medication is generally held for these procedures, but the timing is decided by the bariatric surgical team.

Emergency surgery

In emergency cases where there is no opportunity to hold the medication or modify the diet, the assumption is that the patient may have a "full stomach" regardless of fasting status. The anesthesia plan is adjusted accordingly — typically rapid sequence induction with cricoid pressure and aspiration precautions. The decision to operate is not delayed for a GLP-1 alone in a true emergency.

Elective procedures during dose escalation

If you are still in the dose-titration phase of your GLP-1 — for example, just bumped up from 0.5 mg to 1 mg of Wegovy, or from 5 mg to 7.5 mg of Zepbound — the 2024 guidance recommends waiting until you have completed escalation and are on a stable maintenance dose before scheduling elective surgery. The dose-escalation period carries the highest risk of GI symptoms and slowest gastric emptying.

What Anesthesia Teams Now Do Differently

From the anesthesia provider's perspective, the practical changes since the 2024 update include:

• More routine use of point-of-care gastric ultrasound for higher-risk patients on GLP-1s. This is a 5–10 minute bedside scan that visualizes whether the stomach contains residual solid food, fluid, or is empty.
• More liberal use of rapid sequence induction for patients on weekly GLP-1s, even when other aspiration risk factors are absent.
• Closer questioning about dose escalation status, current GI symptoms, and last dose timing during the preoperative interview.
• Collaborative protocols with surgical and prescribing services so that GLP-1 decisions are made in advance rather than on the day of surgery.

Returning to Your Medication After Surgery

The current guidance does not specify a uniform restart timeline. Most clinicians recommend resuming GLP-1 therapy when the patient is tolerating oral intake, has return of normal bowel function, and is no longer on opioid-based pain management at high doses (which independently delays gastric emptying). For weekly formulations, this often means resuming at the next scheduled weekly dose. For daily formulations, this often means resuming the day after surgery if uncomplicated.

If the medication was held for a week or more before surgery, some clinicians recommend restarting at a lower dose and re-titrating to the prior maintenance dose. Others restart at the maintenance dose if the patient was previously well-tolerating it. This decision belongs to your prescribing clinician.

The Bigger Picture

The evolution from the 2023 ASA guidance to the 2024 multi-society update is a useful illustration of how rapidly emerging-evidence specialties update their recommendations. The 2023 guidance was reasonable given the available data. The 2024 update reflects sixteen months of accumulated clinical experience showing that the original recommendation, while safe, was unnecessarily aggressive for most patients — leading to weeks of disrupted weight management and glycemic control without proportional safety benefit.

For patients, the practical takeaway is that the simple rule has been replaced with an individualized one. That requires more conversation with your care team, but the conversation is worth having. Holding a GLP-1 for a full week means missed weight loss progress, possible weight regain, disrupted appetite control, and (for diabetes patients) compromised glycemic control. If you can safely continue your medication with a 24-hour clear liquid diet and standard aspiration precautions, that is now the preferred path for most.

Choosing a Provider Who Stays Current

Telehealth GLP-1 platforms vary widely in how they handle perioperative questions. Some still send patients the 2023 "hold for a week" instructions by default. Others have updated their protocols to reflect the 2024 multi-society guidance and coordinate with surgical teams when patients have procedures scheduled. If you anticipate any surgery during your GLP-1 therapy, choosing a provider whose clinical team stays current with multi-society updates is part of due diligence.

Affiliate Disclosure: Some provider links on this page are affiliate links. If you sign up through these links, we may receive compensation at no additional cost to you. This does not influence our editorial content, sourcing standards, or coverage of perioperative guidance. This article is informational only and does not constitute medical advice. Decisions about whether to hold or continue your GLP-1 medication before surgery should be made by your anesthesia and surgical teams in consultation with your prescribing clinician.