Perioperative management of GLP-1 receptor agonists: a structured narrative review with considerations relevant to neurosurgical patients.

PURPOSE: The use of glucagon-like peptide-1 receptor agonists (GLP-1RAs) is increasing in the treatment of obesity and type 2 diabetes mellitus. Some patients taking these medications undergo cranial or spinal surgical procedures. Delayed gastric emptying is a key mechanism of action for these medications. Despite the standard preoperative fasting period, there is a risk of residual gastric contents remaining in the perioperative period. Since neurosurgical patients face a risk of postoperative complications such as aspiration, delayed extubation, and postoperative nausea and vomiting, there is a need for a clinically focused review.

METHODS: We performed a structured narrative review of perioperative studies, gastric ultrasound reports, meta-analyses, and professional society guidance addressing GLP-1RA use in anesthesia, surgery, and procedural sedation. Evidence was qualitatively synthesized with particular attention to procedural and physiologic factors relevant to neurosurgical practice, including urgent surgery, prone positioning, posterior fossa pathology, and baseline bulbar dysfunction.

RESULTS: Current evidence consistently links the use of GLP-1 receptor agonists (GLP-1RAs) with an increased likelihood of gastric retention, particularly during dose escalation and in patients with active gastrointestinal symptoms. However, population-level studies and meta-analyses have not shown an increase in pulmonary aspiration rates. Although aspiration is not very common in neurosurgical patients, when it does occur, its consequences may be more severe than expected. Direct evidence specific to neurosurgery in the perioperative setting remains limited.

CONCLUSION: A practical perioperative management approach structured according to risk level can assist in assessing the patient's symptoms and stage of treatment. It can also ensure that procedure-specific risk factors are taken into account, appropriate risk-reduction measures are selected, and the resumption of medication in the postoperative period is individualized. Due to the limited evidence specific to neurosurgery, these assessments should not be interpreted as evidence-based neurosurgery guidelines. They should instead be viewed as expert-driven extrapolations adapted from the broader perioperative literature to neurosurgical practice.