GLP-1 drugs show promise for preoperative weight loss

Editor's Note

Glucagon-like peptide-1 (GLP-1) receptor agonists may offer orthopedic patients with obesity and type 2 diabetes a powerful tool for preoperative weight loss and potential disease modification, according to a July 10 review article in The Journal of Bone and Joint Surgery. However, the agents carry perioperative risks that warrant careful consideration and multidisciplinary planning.

As detailed in the article, GLP-1 receptor agonists (GLP-1 RAs)—originally developed for glycemic control—are widely used for weight loss. Although some studies suggest potential benefit for surgical outcomes, the article emphasizes that evidence remains mixed and context-dependent.

The review outlines guidelines from the American Society of Anesthesiologists (ASA), which recommends withholding daily GLP-1 RAs on the day of elective surgery and weekly formulations for seven days prior. If patients exhibit gastrointestinal symptoms on the day of surgery or did not withhold the medication, ASA advises delaying the procedure or proceeding with full stomach precautions. In trauma cases, anesthesiologists may rely on point-of-care gastric ultrasound to assess aspiration risk.

As for outcomes associated with orthopedic surgery, one study found no increase in complications after total shoulder arthroplasty. For total knee and hip arthroplasty, GLP-1 RA use was linked to lower periprosthetic joint infection and readmission rates, though one study also found higher rates of acute kidney injury, pneumonia, myocardial infarction, and hypoglycemia. In a propensity-matched cohort undergoing cervical decompression and fusion, semaglutide was not associated with increased short-term complications. The review also notes that much of the evidence comes from retrospective databases with limited follow-up.

Emerging research suggests GLP-1 RAs may have anti-inflammatory effects relevant to osteoarthritis, the authors write. In special populations, preclinical studies suggest GLP-1 RAs may promote bone formation and reduce resorption, potentially helping elderly patients at risk of osteoporosis. The article also highlights evidence of cardiovascular benefits, including a 13% risk reduction in major cardiac events in high-risk patients taking liraglutide, and symptom improvements in heart failure patients taking semaglutide. In adolescents, GLP-1 RAs may offer benefits for weight loss, though long-term skeletal effects remain unclear.

Overall, the review underscores the importance of individualized perioperative planning. Orthopedic surgeons should coordinate with primary care and endocrine teams. While these agents may reduce modifiable risk factors, initiating them for preoperative weight loss raises concerns about access and equity, particularly given cost barriers. The authors call for additional research to clarify long-term surgical outcomes, optimal protocols, and patient selection strategies.