Overview
Representatives from ANZCA, the Gastroenterological Society of Australia, the Australian Diabetes Society, and the National Association of Clinical Obesity Services and Australian and New Zealand Metabolic and the Obesity Surgery Society have developed revised recommendations for patients taking GLP-1 receptor agonists and dual GLP-1/GIP receptor co-agonists prior to anaesthesia or sedation.
Why is this guidance necessary?
Recent case reports and large case series have shown a risk of retained gastric contents and cases of pulmonary aspiration during sedation for endoscopic procedures or general anaesthesia in individuals treated with GLP-1RAs or GLP-1/GIPRAs.
This has been highlighted by the Australian Therapeutic Goods Administration (TGA), which has released a Medicines Safety Update with new warnings to be added to the product information of this class of drugs about risks during anaesthesia or deep sedation. Specific warnings include the risk of aspiration for patients, the need for patients to inform their anaesthetist they are taking these medications, and for anaesthetists to consider the heightened risk of aspiration and to manage such patients accordingly.
Pulmonary aspiration, although rare, is a high-risk and potentially fatal complication. Given the popularity of and rapid rise in the use of this class of receptor agonists, the need for this guidance has become increasingly urgent. The recommendations aim to mitigate the risks for patients undergoing procedures requiring anaesthesia or sedation.
One risk mitigation strategy is for elective patients to have a clear fluid diet for the day before surgery. A patient information guide has been developed to help anaesthetists and preoperative staff give advice to patients taking these drugs. The information guide can be customised for individual hospital use.
FAQs
Frequently asked questions related to the GLP1RA and GLP1/GIPRA perioperative management clinical guidance:
What has changed since the guidance was first published in 2024?
The guidance was updated for clarity and to be more unambiguous regarding the recommendation to continue these medications and to not cease them prior to the procedure. It remains unclear how long cessation of the medication would need to be for a meaningful effect on gastric emptying. Moreover the implications for diabetic stability and obesity management are not trivial if the medication is ceased. The guidance has also been updated to include the 24-hour fluid diet recommendation.
In June 2025, the TGA issued a medicines safety update requiring consideration be given to the risk of delayed gastric emptying and aspiration when providing anaesthesia or deep sedation for patients using these drugs. This safety update reinforces the importance of this guidance.
Why do these recommendations differ from other published recommendations?
These recommendations are very consistent with the key points from the most current international guidelines, especially those published, in 2024 and 2025, by multi-society groups in both the US and the UK1-3.
What is meant by "24-hour clear fluid" diet?
Suggested patient information regarding the type of clear fluids that can be consumed during the day before a patient’s procedure is provided in the patient information sheet provided in the links on this web page. During this period, there are no specified limits on the volume of clear fluids that can be consumed.
When should the 24-hour fluid diet begin?
Ideally, it should commence from waking on the day before and continue until the start of the "standard six-hour fasting period”, which allows clear liquids, though limited in volume, until two hours prior to the procedure.
Will a 24-hour clear fluid diet guarantee an empty stomach?
No fasting protocol in any patient will guarantee an empty stomach. In addition, many of these patients will have additional risk factors for delayed gastric emptying (for example, diabetes or obesity) which must be taken into consideration. From the evidence currently available, it is possible that a 24-hour fluid diet will maximise the chances of reducing residual gastric contents to a safe level.
What about diabetic patients and the 24-hour fluid fast?
The impact on glycaemic management is most significant for diabetics (either type 1 or 2) who require insulin given most of the carbohydrates in clear fluids are simple sugars. Referral to these patients’ endocrinologist for advice is recommended.
A 24-hour fluid diet is likely to be an impost on my patients.
Yes, it is an extra undertaking in preparation for elective surgery. All options should be discussed with the patient. It should be remembered that all patients having colonoscopy undertake a similar fluid/semi-solid diet with bowel prep solution for 24 hours prior to their procedure.
What is meant by the "standard six-hour fasting period"?
This is the preprocedural fasting as described in ANZCA PG07 Pre-anaesthesia consultation Appendix 1. On the day of the procedure, from six hours prior to the procedure until two hours prior to the procedure, patients should have access to limited (< 200ml/h or half a cup) clear liquids if thirsty. No solid or semi-solid food is permitted.
Why is "Sip Til Send" not currently recommended?
This is only out of caution. Although fluids don’t present the same aspiration risk as semi-solids or solids, there is still delayed gastric emptying for fluids, even though the delay is not as marked as for food, in patients using these drugs.
Hence a two-hour fast for all fluids prior to the procedure seems reasonable. We would look forward to changing this if safety evidence emerges.
Why is erythromycin recommended as a prokinetic because, as a drug, it carries its own risks?
The evidence is presented in the guidance document. Erythromycin has been shown to be of benefit in enhancing gastric emptying in patients taking GLP1RAs. The use of any prokinetic drug should follow the recommendations in the product information, including contraindications and consideration of side effects (which can include gastric cramping).
Will these guidelines be updated?
When substantive new information or evidence emerges, which might meaningfully alter these clinical points, the four contributing organisations will provide a review and update if necessary.
References
1. El-Boghdadly K, Dhesi J, Fabb P, Levy N, Lobo DN, McKechnie A, et al. Elective peri-operative management of adults taking glucagon-like peptide-1 receptor agonists, glucose-dependent insulinotropic peptide agonists and sodium-glucose cotransporter-2 inhibitors: a multidisciplinary consensus statement: A consensus statement from the Association of Anaesthetists, Association of British Clinical Diabetologists, British Obesity and Metabolic Surgery Society, Centre for Perioperative Care, Joint British Diabetes Societies for Inpatient Care, Royal College of Anaesthetists, Society for Obesity and Bariatric Anaesthesia and UK Clinical Pharmacy Association. Anaesthesia. 2025;80(4):412-24.
2. Kindel TL, Wang AY, Wadhwa A, Schulman AR, Sharaiha RZ, Kroh M, et al. Multisociety clinical practice guidance for the safe use of glucagon-like peptide-1 receptor agonists in the perioperative period. Surg Obes Relat Dis. 2024;20(12):1183-6.
3. Oprea AD, Ostapenko LJ, Sweitzer B, Selzer A, Irizarry-Alvarado JM, Hurtado Andrade MD, et al. Perioperative management of patients taking glucagon-like peptide 1 receptor agonists: Society for Perioperative Assessment and Quality Improvement (SPAQI) multidisciplinary consensus statement. Br J Anaesth. 2025.