Perioperative Considerations for the Podiatric Surgical Patient on GLP-1 Therapy: A Surgeon’s Perspective

For podiatric surgeons, the shift to using GLP-1 receptor agonists introduces new perioperative considerations. A thoughtful, multidisciplinary approach is essential to safely optimize outcomes in this growing patient population.

Key Takeaways

1.     Preoperative risk stratification must go beyond BMI and A_1c. Surgeons should clarify the indication for GLP-1 therapy, assess gastric emptying risk, and evaluate nutritional and metabolic markers—including protein status and key micronutrients—prior to surgical planning.
2.     Anesthesia coordination is critical. Delayed gastric emptying associated with GLP-1 agents increases aspiration risk, prompting updated perianesthesia guidance and, in some cases, consideration of regional techniques to mitigate perioperative risk.
3.     Postoperative healing requires proactive monitoring. Appetite suppression, glycemic variability, and potential nutrient deficiencies can impact wound and bone healing, making individualized medication resumption and close metabolic follow-up essential for optimal recovery.

Glucagon-like peptide-1 (GLP-1) receptor agonists have rapidly transformed the medical management of obesity, type 2 diabetes mellitus, and obesity-related conditions such as obstructive sleep apnea.^1-3 In 2026, these medications are no longer viewed as adjunctive therapy but rather as primary treatment for metabolic disease in many patients.^2,4 As a result, we as podiatric surgeons are encountering an ever-growing population of surgical candidates actively using GLP-1 therapy at the time of operative planning.

While the systemic benefits of GLP-1 therapy are well established, including significant weight loss, improved glycemic control, decreased metabolic inflammation and cardiometabolic risk reduction, the perioperative implications of these medications require careful consideration. From delayed gastric emptying and anesthesia risk to nutritional deficiencies affecting wound and bone healing, GLP-1 therapy introduces new variables into our surgical decision-making.  

Preoperative Considerations

Understanding the Indications for GLP-1 Therapy. Not all GLP-1 patients carry the same surgical risk. A key first step is identifying why the patient is on therapy. Patients using GLP-1 agents for obesity alone may tolerate medication holds differently than patients with long-standing diabetes now managed primarily with GLP-1 therapy.² Those prescribed GLP-1s for obesity-related sleep apnea often represent a subset of patients with severe metabolic dysfunction, higher BMI, and increased anesthesia risk. Regardless of underlying cause, careful discussion should be had between the podiatric clinician and the patient to address the real concern over weight gain if and when there is a 1–2 week hold on the medication prior to surgery and a potential 3–4 week hold after procedure as well.  

Delayed Gastric Emptying and Aspiration Risk. GLP-1 receptor agonists slow gastric emptying, contributing to early satiety and weight loss but increasing the risk of residual gastric contents at the time of anesthesia.^5-7 Case reports and perianesthesia literature have raised concerns regarding aspiration risk despite adherence to standard fasting guidelines.^6,8 Currently most outpatient centers require at least 7 days from last GLP-1 injection, many recommending 14 days prior to allow for full gastric emptying. These risks have prompted significantly updated perioperative guidance from anesthesia societies regarding GLP-1 medication management prior to surgery,⁹ even as compared to 2025 guidelines.

Metabolic and Nutritional Assessment. Rapid weight loss associated with GLP-1 therapy may lead to reduced protein intake and micronutrient deficiencies, which are critical to wound and bone healing.^10-12 Vitamin D deficiency, hypoalbuminemia, and inadequate protein intake have been associated with delayed osseous healing and increased postoperative complications.^11,13 Specifically, Vitamin B₁ deficiency alone can cause delayed wound healing and neuropathy type symptoms postoperatively as well. A full comprehensive metabolic panel with review of B₁₂, B₁, B₆, vitamin D, and albumin should preoperatively may help maximize healing potential.

Intraoperative Considerations

Clear communication with anesthesia teams is essential. GLP-1 use should be explicitly documented and discussed preoperatively. Regional anesthesia techniques may reduce perioperative risk in select patients undergoing foot and ankle procedures.^9,16 Specifically, if a procedure is able to be performed with a regional or local anesthetic block, this may shift surgeon perspectives regarding use of IV sedation or general anesthesia to allow for GLP-1 patients to continue their medications. 

Postoperative Considerations

Postoperative healing in patients using GLP-1 medications require close monitoring. Reduced appetite or nausea may impair protein intake during a critical recovery window.^10,12 Careful glycemic monitoring remains essential, particularly in patients using GLP-1 receptor agonists as primary diabetes therapy.^2,4 The timing of GLP-1 resumption postoperatively should be individualized,^9,14 with current recommendations from the American Diabetes Association (resuming medications 7–14 days postoperatively).  

Conclusion

GLP-1 medications have fundamentally changed the metabolic landscape of surgical patients. For podiatric surgeons, these therapies introduce new perioperative considerations that extend beyond traditional risk assessment models. By implementing thoughtful perioperative protocols and multidisciplinary collaboration, surgeons can work to optimize outcomes while minimizing complications and allowing their patients the best opportunity for success with their foot and ankle procedures.  

Dr. Lockwood is in private practice with Heartland Foot & Ankle Associates in Bloomington, IL. 

References
1. Davies MJ, et al. Management of hyperglycemia in type 2 diabetes, 2022. Diabetes Care. 2022;45(11):2753-2786.
2. American Diabetes Association. Standards of Care in Diabetes—2024. Diabetes Care. 2024;47(Suppl 1):S1-S350.
3. Wilding JPH, et al. Once-weekly semaglutide in adults with overweight or obesity. N Engl J Med. 2021;384:989-1002.
4. Garvey WT, et al. Tirzepatide versus semaglutide for obesity treatment. N Engl J Med. 2022;387:205-216.
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6. Van Ryswyk E, et al. Pulmonary aspiration associated with GLP-1 receptor agonists. Anaesthesia. 2023;78(6):735-742.
7. Buse JB, et al. Mechanisms of action of GLP-1 receptor agonists. Lancet. 2020;395(10224):150-160.
8. Gudeman J, et al. Aspiration risk with GLP-1 receptor agonists during anesthesia. Anesth Analg. 2023;137(2):e45-e47.
9. American Society of Anesthesiologists. Consensus-based guidance on preoperative management of patients on GLP-1 receptor agonists. 2023.
10. Mechanick JI, et al. Clinical practice guidelines for nutrition in weight loss therapy. Endocr Pract. 2019;25(12):1346-1359.
11. Harris AH, et al. Nutritional deficiency and bone healing. J Bone Joint Surg Am. 2013;95(9):e55.
12. Wolfe RR. The underappreciated role of muscle and protein in recovery. Am J Clin Nutr. 2017;105(3):475-482.
13. Holick MF. Vitamin D deficiency. N Engl J Med. 2007;357:266-281.
14. Joshi GP, et al. Perioperative management of diabetes medications. Anesthesiology. 2021;134(4):645-662.
15. Marso SP, et al. Cardiovascular outcomes with GLP-1 receptor agonists. N Engl J Med. 2016;375:311-322.
16. Sites BD, et al. Regional anesthesia and patient safety. Reg Anesth Pain Med. 2020;45(7):547-552.

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