Perioperative management of GLP-1 receptor agonists and SGLT2 inhibitors: An updated review for anesthesiologists

ABSTRACT

The widespread adoption of glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium–glucose linked transporter-2 (SGLT2) inhibitors have substantially improved glycemic control and cardiometabolic outcomes in patients with diabetes and related conditions. However, their increasing perioperative use has introduced important safety considerations for anesthesiologists. GLP-1RAs are associated with delayed gastric emptying, raising concerns regarding aspiration risk, while SGLT2 inhibitors have been linked to euglycemic diabetic ketoacidosis (EDKA), particularly in the context of surgical stress and perioperative fasting. This review synthesizes evolving evidence and international guidance to inform contemporary perioperative management of these agents. For GLP-1RAs, early recommendations advocating routine preoperative cessation have been increasingly challenged by recent large-scale outcome data demonstrating no increase in clinically significant aspiration under modern anesthetic practice, supporting an individualized, risk-based approach with targeted mitigation strategies for higher-risk patients. In contrast, perioperative guidance for SGLT2 inhibitors has converged toward preoperative discontinuation to minimize EDKA risk. The review highlights the central role of anesthesiologists in coordinating multidisciplinary, patient-centered care that balances metabolic safety with preservation of established cardiovascular and renal benefits.