Originally published by our sister publication Specialty Pharmacy Continuum

By Marcus A. Banks

Glucagon-like peptide-1 (GLP-1) agonists and sodium-glucose cotransporter-2 (SGLT2) inhibitors should be temporarily withheld prior to elective surgery to avoid complications, according to a presentation at the Critical Care Congress 2025, in Orlando, Fla. 

Data routinely collected in the electronic health record (EHR) can guide these decisions, said Laura Ebbitt, PharmD, BCCP, a surgical acute care pharmacist at the University of Kentucky (UK) Chandler Medical Center, in Lexington.

Delayed gastric emptying caused by GLP-1 agonists might mean food is still in the patient’s stomach when surgery starts, increasing the risk for aspiration pneumonia, Dr. Ebbitt said. Remaining on an SGLT2 inhibitor before surgery increases the risk for euglycemic diabetic ketoacidosis (eDKA), she added.

“We really leverage our medical record,” said Dr. Ebbitt, who used to look in multiple different sources of patient data to determine when to withhold GLP-1 agonists and SGLT2 inhibitors based on factors such as dose strength and the number of days before surgery. Today that process is much easier.

“Everything’s in one place; it’s beautiful,” Dr. Ebbitt said.

The American Diabetes Association recommends withholding SGLT2 inhibitors three or four days prior to surgery (Diabetes Care 2021;44[suppl_1]:S211-S220), with bridging medications if needed. Basic metabolic panels may not capture the risk of eDKA if practitioners are only looking at the patient’s glucose levels, Dr. Ebbitt noted.

For safety’s sake, it is better to stop the SGLT2 inhibitor even if everything looks fine.

“It’s only when you look at their anion levels that the problem appears,” Dr. Ebbitt said.

Current guidance regarding GLP-1 withholding, from a consortium including the American Gastroenterological Association and the American Society of Anesthesiologists, suggests sometimes withholding a single dose the day before surgery if the patient takes a GLP-1 agonist every day, and one weekly dose with a weekly cadence (Clin Gastroenterol Hepatol 2024:S1542-3565[24]00910-8).

Per the guidance, many people can continue taking GLP-1 agonists until surgery. But if a patient is in the dose escalation phase of the medication, this increases the risk for delayed gastric emptying and a temporary pause may be appropriate. This detail, ideally, will be included in a patient’s EHR. But if the EHR record is incomplete, UK practitioners close that information gap by asking patients what medications they are taking in the leadup to surgery, Dr Ebbitt noted. But she recommended framing the question about use of GLP-1 agonists carefully.

“Ask someone if they [have taken] any injectable medications” prior to surgery, Dr. Ebbitt advised, instead of asking “what prescriptions do you take?” Many people get GLP-1s from private compounders rather than their primary care provider and so may not perceive them as a prescription, she explained.

Dr. Ebbitt stressed, however, that the GLP-1 withholding guidance is expert opinion and may change as new evidence emerges.

Dr. Ebbitt reported no relevant financial disclosures.