Perioperative GLP-1 RA use or continuation in adults with obesity undergoing elective non-bariatric surgery was not consistently associated with an increased risk of clinically significant aspiration.
Systematic Review
Does perioperative GLP-1 RA use increase the risk of pulmonary aspiration and delayed gastric emptying in adults with obesity undergoing elective non-bariatric surgery?
Perioperative GLP-1 RA use in adults with obesity undergoing elective non-bariatric surgery is associated with increased residual gastric contents but no consistent increase in clinically evident aspiration, precluding firm recommendations for routine discontinuation.
Background Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are increasingly prescribed for obesity and type 2 diabetes mellitus (T2DM), resulting in a growing number of patients presenting for elective non-bariatric surgery while receiving these agents. Concerns regarding delayed gastric emptying and perioperative aspiration risk have led to inconsistent guidance on whether GLP-1 RAs should be continued or withheld before surgery, and the broader effect of perioperative exposure on postoperative outcomes remains poorly characterised. Methods We conducted a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, prospectively registered with the International Prospective Register of Systematic Reviews. MEDLINE, Embase, the Cochrane Library, Scopus, and Web of Science were searched from January 2015 to October 2025. Observational studies enrolling adults with obesity undergoing elective non-bariatric procedures under general or regional anaesthesia were included if they reported postoperative outcomes according to any classification of perioperative GLP-1 RA exposure (e.g., continuation versus discontinuation, recent versus non-recent use, or use versus non-use). Primary outcomes were pulmonary aspiration and delayed gastric emptying or increased residual gastric contents. Secondary outcomes included postoperative nausea and vomiting, perioperative metabolic events, and broader surgical outcomes. Additional postoperative outcomes identified during data extraction were also captured descriptively. Risk of bias was assessed using the ROBINS-I tool. Due to substantial heterogeneity, a narrative synthesis was undertaken. Results Seven observational cohort studies were included (one prospective, six retrospective; sample sizes 426 to 275,970). None employed a randomised or fully parallel comparison of continuation versus discontinuation; most compared GLP-1 RA users with non-users, one was a single-arm continuation cohort, and two incorporated within-user discontinuation-timing analyses. Aspiration events were rare across all studies, with no consistent increase in risk associated with GLP-1 RA use or continuation. Several endoscopy-based cohorts reported higher rates of residual gastric contents or delayed gastric emptying among users, but this did not translate into a measurable increase in clinically evident aspiration. In orthopaedic and spine surgery cohorts, GLP-1 RA use was associated with significantly higher rates of nonunion, pseudarthrosis, and dysphagia, a discordant cellulitis signal, and, in one cohort, significantly lower mortality and cardiac arrest; these outcomes were not prespecified and should be interpreted as exploratory. Overall certainty of evidence was low to very low. Conclusions Aspiration events were rare across predominantly observational comparisons of GLP-1 RA users and non-users, with no consistent increase in clinically significant aspiration observed with continuation or use. This evidence is indirect, of low to very low certainty, and precludes reliable inference regarding the safety of routine continuation. Exploratory orthopaedic and spine surgery findings suggest the perioperative risk–benefit profile of GLP-1 RAs may vary by surgical context and warrant confirmation in future studies. These findings do not support a firm recommendation for or against routine discontinuation before elective non-bariatric surgery; management should instead be individualised according to symptom burden, procedural risk, and surgical context.
Al‐Majmuei et al. (2026) conducted a systematic review in Obesity undergoing elective non-bariatric surgery. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) vs. Non-users or discontinuation was evaluated on Pulmonary aspiration and delayed gastric emptying or increased residual gastric contents. Perioperative GLP-1 RA use or continuation in adults with obesity undergoing elective non-bariatric surgery was not consistently associated with an increased risk of clinically significant aspiration.