Perioperative Management of Semaglutide in Total Joint Arthroplasty: Optimal Timing for Discontinuation
Patients using glucagon-like peptide-1 receptor agonists (GLP-1A) who undergo total joint arthroplasty (TJA) face increased risks of anesthesia-related complications depending on the timing of medication cessation. The study results, which were presented at the American Academy of Orthopaedic Surgeons 2025 Annual Meeting, showed that stopping semaglutide at least 14 days before surgery minimized the risk of delayed emergence from anesthesia, aspiration, aspiration pneumonitis, and conversion to intubation. The highest complication rates were observed in patients who continued semaglutide use through surgery.1
“GLP-1 agonists can delay gastric emptying and cause gastroparesis (paralysis of the stomach), leading to food remaining in the stomach and increasing anesthesia-related risks,” Christopher T. Holland, MD, MS, lead author, total joint arthroplasty surgeon at Campbell Clinic Orthopaedics and a faculty instructor at the University of Tennessee Health Science Center in Memphis, said in a press release.2 “Until this past year, there was a lack of any literature reporting on the perioperative risk profile for patients who take GLP-1 agonists before surgery and the impact on surgical outcomes. With a growing number of patients using these medications for diabetes or to meet certain optimization goals before undergoing hip and knee reconstructive surgery, our aim was to establish evidence-based guidelines on when to discontinue these to enhance patient safety and surgical success.”
This retrospective cohort study used the TriNetX Research Network to analyze patients undergoing total hip or knee arthroplasty from January 2018 to January 2023. A control group of 206,005 patients without semaglutide use was compared with 4164 patients who had used semaglutide before surgery. The semaglutide cohort was categorized based on when the medication was discontinued: 30, 14, 7, 5, 3, or 1 day before surgery, as well as those who continued use through surgery. Propensity-matched cohorts were analyzed, and multivariate logistic regression was used to assess the association between cessation timing and anesthesia-related complications.
Stopping semaglutide 5 days before surgery was an independent risk factor for delayed emergence from anesthesia (odds ratio [OR], 1.59; P = .005), with higher risks for cessation at 3 days (OR 1.84; P < .001) and 1 day (OR 2.23; P < .001).
The risk of aspiration increased when semaglutide was stopped 7 days prior (OR 1.24; P = .002), with further elevations at 5 days (OR 2.53; P < 0.001), 3 days (OR 3.09; P < 0.001), and 1 day (OR 4.96; P < .001). Similarly, aspiration pneumonitis risk increased with cessation at 7 days (OR 1.29; P < .001) and was highest when stopped 5 days (OR 2.74; P < .001) or 1 day (OR 2.74; P < .001) before surgery.
The need for conversion to intubation was significantly associated with discontinuation at 7 days (OR 1.39; P = .0343), with greater risks at 5 days (OR 2.09; P < .001), 3 days (OR 4.68; P < .001), and 1 day (OR 6.37; P < .001). Diabetes itself was not an independent risk factor for any of these complications.
To optimize patient safety, the study authors recommend stopping GLP-1A therapy at least 14 days before surgery.
"To minimize risks of delayed emergence from anesthesia, aspiration, aspiration pneumonitis, and conversion to intubation, ceasing GLP-1A 14 days before surgery is optimal,” the study authors concluded. “Careful planning and coordination in managing GLP-1A in the preoperative period are essential to optimize surgical outcomes."
Reference
1. Chokshi SN, Hou N, Ford MC, et al. Optimal timing for cessation of GLP-1 agonist before elective total hip and knee arthroplasty. Presented at: American Academy of Orthopaedic Surgeons; March 10-14, 2025; San Diego, CA. Accessed March 9, 2025. https://submissions.mirasmart.com/AAOS2025/Itinerary/PresentationDetail.aspx?evdid=2052
2. New study recommends stopping GLP-1 agonists 14 days before total joint arthroplasty to reduce anesthesia risks. AAOS Annual Meeting. Available at: https://aaos-annualmeeting-presskit.org/2025/research-news/new-study-recommends-stopping-glp-1-agonists-14-days-before-total-joint-arthroplasty-to-reduce-anesthesia-risks/. Accessed March 10, 2025.