Balance the benefits, risks of GLP-1 medications in orthopedic surgery
The rapid increase in the use of glucagon-like peptide-1 receptor agonists for weight loss, diabetes management and cardiovascular health has significant implications for orthopedic surgery.
GLP-1 drugs, such as semaglutide (Ozempic/Wegovy, Novo Nordisk) and tirzepatide (Mounjaro, Eli Lilly), provide notable benefits for surgical candidates, particularly in reducing the complications related to obesity and comorbidities. However, their effects on gastric motility, nutrition and muscle mass may pose a risk to patient safety during and after surgery.
GLP-1 drugs promote significant weight loss, often reducing BMI by 10% to 15% during a 6- to 12-month period. Obesity, defined as a BMI greater than 30 kg/m2, is a well-documented risk factor for complications in procedures like total joint arthroplasty. Onggo and colleagues demonstrated in a large systematic review that patients with obesity had a higher risk for all-cause revisions, all complications, including a 1.5% increase in infection, and readmissions. Lowering BMI with the use of GLP-1 medications can mitigate risks and improve surgical outcomes. In addition, patients who have achieved significant weight loss may be able to delay joint replacement surgery.
GLP-1 medications also benefit patients with comorbidities, such as type 2 diabetes and cardiovascular disease. GLP-1 medications enhance glycemic control by reducing HbA1c. Lower perioperative risks, including cardiac events, make surgery safer for patients undergoing procedures such as joint replacement.
Surgical safety
Despite the benefits, GLP-1 medications have risks that may impact surgical safety. Delayed gastric emptying reduces gastric motility, therefore increasing the risk for aspiration during anesthesia induction. Aspiration can result in severe complications, such as aspiration pneumonia, underscoring the need for vigilance. When possible, sedation and spinal or regional nerve blocks can help mitigate aspiration-related complications.
Gastrointestinal effects also present perioperative challenges. Constipation can lead to discomfort and result in poor nutritional intake before surgery. Insufficient nutrition increases the risk for delayed wound healing and infection. Adequate protein intake consistent with nutritional guidelines is vital for the healing of the entire surgical site.
Rapid weight loss caused by GLP-1 medications can also worsen sarcopenia, especially in older patients. GLP-1 drugs may lead to a loss of lean muscle mass along with fat, particularly without resistance training. Muscle mass and function are essential for postoperative recovery in orthopedic surgery, especially when ambulation is critical to postoperative recovery and avoiding complications, such as thromboembolism. Patients who undergo TJA rely on quadriceps and gluteal strength for rehabilitation. Sarcopenia with lower extremity weakness can result in falls, extended hospital stays and poor functional outcomes.
Risk management
Patients on GLP-1 medications require tailored preoperative management to address the risks. Extended fasting guidelines are necessary to minimize aspiration risk. The American Society of Anesthesiologists has issued guidance that recommends patients on GLP-1 agonists fast for 12 to 18 hours for solid foods and 4 hours for clear liquids before surgery. Point-of-care ultrasound to assess gastric contents preoperatively enhances anesthesia decision-making, providing the surgeon with options to delay surgery or use rapid-sequence induction if significant gastric volume is detected.
Nutritional deficits, constipation and other gastrointestinal symptoms should be addressed before surgery. Patients should increase fluid and fiber intake to manage constipation, and a high-protein diet can support muscle maintenance. Creatine also has been recognized as a valuable supplement for muscle health.
Prehabilitation programs, including resistance training, can help preserve muscle mass. Walking is beneficial for cardiovascular health. Programs that specifically target core muscles and large muscle groups of the pelvis and lower extremities, particularly the quadriceps, are critical to re-establishing ambulation and rehabilitation after surgery.
Systemic approach
Orthopedic surgeons should adopt a systematic approach to effectively manage patients on GLP-1 medications. During the initial surgical consultation, ask patients if they are taking any medications for weight loss or diabetes to ensure the identification of all users, including off-label usage. Inquire about the duration of use and total weight loss. Patients early in GLP-1 treatment are more actively losing weight and may have more gastrointestinal adverse events, and prolonged use may increase the risk for sarcopenia.
Documenting total weight loss helps assess the extent of muscle loss and its nutritional impact. Ask patients about their use of nutritional supplement, such as protein powders and creatine. Muscle loss can be mitigated with a high-protein diet or supplements, particularly for patients older than 60 years.
The American Society of Anesthesiologists currently recommends that patients on weekly dosing hold the GLP-1 agonist for 1 week prior to the procedure, and if they are micro-dosing with daily treatment, then the patients should hold the medication on the day of surgery.
However, Chang and colleagues concluded that current guidelines of the top 20 countries with the largest anesthesiology societies are variable without strong evidence-based research to support one opinion over another.
Patients can typically resume GLP-1 medication postoperatively on their usual schedule once oral intake and gastrointestinal function normalize. A nutritional plan for the first 2 to 4 weeks after surgery should include high-protein supplementation to support healing and muscle recovery, especially for procedures like TJA and spine surgery where mobility is critical. Failing to address the related risks may expose health care providers to liability.
GLP-1 medications significantly benefit orthopedic patients by reducing BMI and improving comorbidities. However, their effects on gastric motility, nutrition and muscle mass may present perioperative risks. Surgeons can ensure safer surgeries and better outcomes by adopting a systematic approach of screening for use, assessing treatment progression, optimizing nutrition, adjusting medication timing and planning postoperative care.
References:
- Chang MG, et al. Can J Anaesth. 2024; doi:10.1007/s12630-024-02810-5.
- Joshi GP, et al. American Society of Anesthesiologists consensus-based guidance on preoperative management of patients (adults and children) on glucagon-like peptide-1 (GLP-1) receptor agonists. https://www.asahq.org/about-asa/newsroom/news-releases/2023/06/american-society-of-anesthesiologists-consensus-based-guidance-on-preoperative. Published June 29, 2023. Accessed April 8, 2025.
- Kindel TL, et al. Surg Obes Relat Dis. 2024;doi:10.1016/j.soard.2024.08.033.
- Marso SP, et al. N Engl J Med. 2016;doi:10.1056/NEJMoa1603827.
- Onggo JR, et al. ANZ J Surg. 2021;doi:10.1111/ans.17138.
- Shin D, et al. J Otolaryngol Head Neck Surg. 2023;doi:10.1186/s40463-022-00617-2.
- Wilding JPH, et al. N Eng J Med. 2021;doi:10.1056/NEJMoa2032183.
For more information:
Anthony A. Romeo, MD, is the Chief Medical Editor of Healio | Orthopedics Today. He can be reached at Healio, 6900 Grove Road, Thorofare, NJ 08086; email: orthopedics@healio.com.
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