Navigating Diabetes and Weight Loss Drugs for Safe Surgery

The increasing number of patients using glucagon-like peptide-1 receptor agonists (GLP-1 RAs), a class of medications that mimic a natural gut hormone to help control blood sugar and promote weight loss, and sodium-glucose co-transporter 2 (SGLT2) inhibitors, drugs that help the kidneys remove sugar from the body, presents a growing challenge for perioperative care (the period around surgery). While these drugs offer significant health benefits, their unique mechanisms can introduce specific risks during surgery, such as delayed gastric emptying or metabolic imbalances. This review addresses the critical need for clear, evidence-based guidelines to manage these medications safely around elective procedures, thereby filling the knowledge gap regarding standardized perioperative management protocols for GLP-1 RAs and SGLT2 inhibitors.

The review identified distinct perioperative risks and management strategies for each drug class. For GLP-1 RAs, the highest risk of aspiration (inhaling stomach contents into the lungs) was noted in non-fasters, patients with recent drug initiation, those who had a recent dose escalation, or individuals with active gastrointestinal symptoms. Conversely, asymptomatic patients on stable doses of GLP-1 RAs were deemed safe to continue their medication throughout the perioperative period. For SGLT2 inhibitors, the primary concern was the risk of euglycemic diabetic ketoacidosis (DKA), a serious condition where the body produces high levels of blood acids despite normal blood sugar, particularly in patients also on insulin with prolonged fasting. This risk necessitates a different approach. SGLT2 inhibitors should be held prior to elective procedures to mitigate the risk of euglycemic diabetic ketoacidosis, especially in vulnerable patient populations.