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GLP-1s, sedation and fasting: the aspiration risk and the 2024 reversal

  • MDside
  • October 9, 2026

Key points

  • On GLP-1s, the odds of residual gastric content despite fasting are much higher: OR 5.96 in a meta-analysis and OR 4.29 to 9.85 on gastric ultrasound [1][3].
  • Measured aspiration is not clearly increased: OR 1.04 (95% CI 0.87 to 1.25) in 185,414 patients from observational studies, with low certainty [1].
  • On gastric ultrasound, 42% of semaglutide users vs 7% of controls had solid contents, and the authors conclude the risk persists even after one dose is withheld [3].
  • The 2024 multi-society guidance favors continuing in most patients and a 24-hour liquid diet in high-risk patients [8].

US status (October 2026): Semaglutide and tirzepatide are FDA-approved (Ozempic, Wegovy, Mounjaro, Zepbound). Compounding is limited to named-patient 503A preparations inside FDA’s essentially-a-copy limits. See semaglutide and tirzepatide.

Every practice that sedates GLP-1 patients needs a policy

GLP-1 agonists slow gastric emptying. That is part of how they work, and it becomes your problem whenever a patient arrives for endoscopy, sedation or cosmetic surgery with a supposedly empty stomach. The tirzepatide label itself mentions “rare postmarketing reports of pulmonary aspiration” and states that the available data “are insufficient to inform recommendations to mitigate the risk” [9]. If you run a weight management program and also do procedures under sedation, both sides of your practice touch this.

Residual content is common. Aspiration is not clearly increased.

A 2025 meta-analysis of 28 observational studies separated two outcomes that are often conflated. Residual gastric content: 18 studies with 165,522 patients, OR 5.96 (95% CI 3.96 to 8.98). Pulmonary aspiration: 9 studies with 185,414 patients, OR 1.04 (0.87 to 1.25), both with low certainty. Holding at least one dose was associated with less residual content (OR 0.51), with very low certainty [1].

In a BMJ cohort of 43,365 adults with type 2 diabetes undergoing upper endoscopy, comparing GLP-1 users with SGLT2 inhibitor users, aspiration was 4.15 vs 4.26 per 1,000 (RR 0.98), and aborted procedures doubled: 9.79 vs 4.91 per 1,000 (RR 1.99) [2]. In a study of 84 matched pairs undergoing endoscopy, residual content was 13.1% vs 4.8% (aOR 4.62), with worse mucosal visibility [5].

  • OR 5.96: residual gastric content on GLP-1s (18 studies) [1]
  • OR 1.04: pulmonary aspiration (185,414 patients) [1]
  • 42% vs 7%: solid contents on gastric ultrasound with semaglutide [3]

Gastric ultrasound shows food after a held dose

A 2026 prospective multicenter study scanned the stomachs of 44 semaglutide users and 44 matched controls before elective surgery. “Full stomach”: 49% vs 18% (OR 4.29). Solid contents: 42% vs 7% (OR 9.85). The authors conclude the risk remains elevated even after one semaglutide dose is withheld [3]. In a retrospective series published in the Canadian Journal of Anesthesia, visible content was 19% vs 5% (aOR 5.8), with 5 emergency intubations vs 1 and one aspiration [4].

One practical detail: in an upper-endoscopy series, the risk of solid content (OR 3.80) was not increased when colonoscopy was done the same day, presumably because the patient had followed the liquid diet of bowel prep [6].

The guidance reversed in 16 months

In June 2023 the American Society of Anesthesiologists advised: “Hold GLP-1 agonists a week prior to the procedure/surgery for patients who take the medication weekly” [7]. In October 2024 a joint statement from ASA, AGA, ASMBS, ISPCOP and SAGES changed course: “Most patients should continue taking their glucagon-like peptide-1 (GLP-1) receptor agonists before elective surgery”, and patients at high GI risk “should follow a liquid diet for 24 hours before the procedure” [8].

The debate is still open

The data supporting continued treatment show that aspiration is not measurably increased [1][2]. The 2026 ultrasound data show the stomach is often not empty even after a held dose [3]. Both are true at once.

What this means for you.

  1. Ask every sedation or procedure patient about GLP-1 use, including compounded and online-sourced products, and document the last dose.
  2. Follow the 2024 multi-society statement as the current baseline: most patients continue, and high-GI-risk patients follow a 24-hour liquid diet [8].
  3. When in doubt, gastric ultrasound is a tool for deciding [3]. The pre-procedure liquid diet has the best indirect support [6][8].
  4. Put the policy in writing with your medical director so staff apply it the same way every time.

References

  1. Elkin J, et al. Association between glucagon-like peptide-1 receptor agonist use and peri-operative pulmonary aspiration: a systematic review and meta-analysis. Anaesthesia. 2025;80(7):846-858. PMID 40230298. Link
  2. Alkabbani W, et al. Glucagon-like peptide-1 receptor agonists before upper gastrointestinal endoscopy and risk of pulmonary aspiration or discontinuation of procedure: cohort study. BMJ. 2024;387:e080340. PMID 39438043. Link
  3. Vlaeminck N, et al. Gastric ultrasound in patients receiving semaglutide: a prospective, multicentre, matched control study. Anaesthesia. 2026;81(6):801-809. PMID 41631344. Link
  4. Wu F, et al. Association of glucagon-like peptide receptor 1 agonist therapy with the presence of gastric contents in fasting patients undergoing endoscopy under anesthesia care: a historical cohort study. Can J Anaesth. 2024;71(7):958-966. PMID 38485835. Link
  5. Chapman MB, et al. Effects of glucagon-like peptide-1 receptor agonists on gastric mucosal visibility and retained gastric contents during EGD. Gastrointest Endosc. 2024;100(5):923-927. PMID 38759761. Link
  6. Panchal S, et al. Endoscopy and anesthesia outcomes associated with glucagon-like peptide-1 receptor agonist use in patients undergoing outpatient upper endoscopy. Gastrointest Endosc. 2025;102(2):216-222. PMID 39824444. Link
  7. American Society of Anesthesiologists. Patients taking popular medications for diabetes and weight loss should stop before elective surgery. 28 June 2023. Link
  8. American Society of Anesthesiologists, et al. New multi-society GLP-1 guidance. 29 October 2024. (Kindel TL, et al. Surg Obes Relat Dis. 2024;20(12):1183-1186.) Link
  9. Eli Lilly and Company. Zepbound (tirzepatide) US prescribing information, revised 08/2026. Link

This is general information, not medical or legal advice. Rules vary by state and change. Confirm your own facts with counsel.

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Medical direction. Victor D. Cruz, MD, Systems Medical Director, licensed in Florida (ME117105) and New York, directs structure, corporate practice of medicine, delegation and good faith exams. This states who carries clinical responsibility for this subject area. It is not a page-level review: pages that have been reviewed name the reviewer and show the date. How this site is written and checked.