Perioperative Management of GLP-1 Receptor Agonists: Balancing Aspiration Risk with Therapeutic Benefit

The prescribing of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) has surged for the treatment of diabetes and obesity, with more than 15 million users worldwide. These medications also delay gastric emptying through neural mechanisms, increasing the risk for perioperative aspiration during anaesthesia and sedation. This narrative review aims to bridge the gap between evidence and clinical practice regarding the use of GLP-1 RAs in the perioperative period by critically evaluating changing clinical recommendations to inform a balance between the risks of aspiration and the potential surgical benefits. Important conclusions drawn from recent meta-analyses involving over 300,000 patients report that while the retained gastric contents are significantly increased (fivefold to tenfold increase; odds ratio 3.35–36.97), rates of pulmonary aspiration (0.1% to 0.2%) remain quite low, with no significant increase in comparison to control groups. Guidelines have evolved considerably from routine medication cessation in 2023 to GLP-1 RA continuation with individualised risk assessment in 2024–2025, illustrating increasing acknowledgment that certain theoretical risks may be underestimated. The evidence supports shared decision-making frameworks, where patient needs, procedure timeframes, and other management approaches, such as liquid diets, ultrasound evaluation of the stomach preoperatively, or anaesthetic modification tailored techniques, are considered primary drivers for care rather than rigid guidelines. The principle under which GLP-1 RAs should be managed has shifted to strategy layering—restoring calculator systems tailored to patients, rather than blanket medication cessation triggers that dominated prior models’ suspension approach.