Perioperative and periprocedural management of GLP-1 receptor-based agonists and SGLT2 inhibitors: narrative review and the STOP-GAP and STOP DKA-2 algorithms

Ronald M Goldenberg; Jeremy D Gilbert; Robyn L Houlden; Tayyab S Khan; Sapna Makhija; C David Mazer; Jill Trinacty; Subodh Verma

doi:10.1080/03007995.2025.2458538

Perioperative and periprocedural management of GLP-1 receptor-based agonists and SGLT2 inhibitors: narrative review and the STOP-GAP and STOP DKA-2 algorithms

Curr Med Res Opin. 2025 Mar;41(3):403-419. doi: 10.1080/03007995.2025.2458538. Epub 2025 Jan 31.

Authors

Ronald M Goldenberg¹, Jeremy D Gilbert^{2

3}, Robyn L Houlden⁴, Tayyab S Khan^{5

6}, Sapna Makhija⁷, C David Mazer^{8

9

10

11}, Jill Trinacty^{12

13

14}, Subodh Verma^{11

15

16}

Affiliations

¹ LMC Diabetes & Endocrinology, Concord, Canada.
² Division of Endocrinology and Metabolism, Sunnybrook Health Sciences Centre, Toronto, Canada.
³ Department of Medicine, University of Toronto, Toronto, Canada.
⁴ Division of Endocrinology and Metabolism, Queen's University, Kingston, Canada.
⁵ Division of Endocrinology and Metabolism, St. Joseph's Healthcare Centre, London, Canada.
⁶ Department of Medicine, Western University, London, Canada.
⁷ GI Health Centre, Burlington, Canada.
⁸ Department of Anesthesia, St. Michael's Hospital of Unity Health Toronto, Toronto, Canada.
⁹ Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada.
¹⁰ Department of Physiology, University of Toronto, Toronto, Canada.
¹¹ Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada.
¹² LMC Diabetes & Endocrinology, Ottawa, Canada.
¹³ Department of Medicine, Queensway Carleton Hospital, Ottawa, Canada.
¹⁴ Bruyère Continuing Care, Ottawa, Canada.
¹⁵ Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Canada.
¹⁶ Department of Surgery, University of Toronto, Toronto, Canada.

PMID: 39871617
DOI: 10.1080/03007995.2025.2458538

Abstract

The GLP-1 receptor-based agonists (GLP-1RAs) and SGLT2 inhibitors (SGLT2i) are major twenty first century breakthroughs in diabetes and obesity medicine but there are important safety considerations regarding the perioperative and periprocedural management of individuals who are treated with these agents. GLP-1RAs have been linked to an increased risk of retained gastric contents and pulmonary aspiration while SGLT2i can be associated with diabetic ketoacidosis. This manuscript provides a narrative review of the available evidence for perioperative and periprocedural risks in people prescribed GLP-1RAs and SGLT2i. The authors provide expert opinion-driven recommendations and algorithms on how to safely manage GLP-1RAs and SGLT2i under perioperative/periprocedural settings.

Keywords: GLP-1RA; SGLT2i; aspiration; ketoacidosis; perioperative; periprocedure.

Publication types

Review

MeSH terms

Algorithms
Diabetes Mellitus, Type 2* / drug therapy
Diabetic Ketoacidosis* / chemically induced
Diabetic Ketoacidosis* / prevention & control
Glucagon-Like Peptide-1 Receptor Agonists*
Humans
Hypoglycemic Agents* / adverse effects
Hypoglycemic Agents* / therapeutic use
Perioperative Care* / methods
Sodium-Glucose Transporter 2 Inhibitors* / adverse effects
Sodium-Glucose Transporter 2 Inhibitors* / therapeutic use

Substances

Sodium-Glucose Transporter 2 Inhibitors
Glucagon-Like Peptide-1 Receptor Agonists
Hypoglycemic Agents