Perioperative management of GLP-1 receptor agonists: adult evidence and future directions

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are increasingly used for the treatment of type 2 diabetes and obesity, resulting in a growing number of patients receiving these medications during the perioperative period. Delayed gastric emptying associated with GLP-1RA therapy has raised concern regarding residual gastric contents and the potential for pulmonary aspiration despite adherence to standard fasting guidelines. Current evidence consistently demonstrates an increased incidence of residual gastric contents among patients receiving GLP-1RAs; however, a corresponding increase in pulmonary aspiration has not been established. Interpretation of the available literature is limited by the rarity of aspiration events, predominantly retrospective study designs, heterogeneous procedural settings, and potential confounding factors. As evidence has evolved, perioperative recommendations have shifted from routine medication withholding toward individualized risk assessment incorporating treatment initiation or dose escalation, gastrointestinal symptoms, comorbidities affecting gastric emptying, dietary preparation, and anesthetic technique. Gastric point-of-care ultrasound may provide additional information in selected patients, although operator dependence, difficulties in quantitative assessment, and uncertain thresholds for clinically significant gastric volumes limit its ability to independently guide management. Pediatric-specific evidence remains particularly limited, with current recommendations largely extrapolated from adult data despite developmental and practical differences that may influence perioperative assessment. Prospective studies are needed to better define aspiration risk, identify high-risk patients, establish clinically meaningful gastric ultrasound thresholds, and determine the effectiveness of perioperative risk-reduction strategies.