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Epitope Health teaches what published research and FDA labels say, and how strong that evidence is. It cannot know your situation, and nothing here is a diagnosis, a dose for one person, or a decision about whether a food, medicine or procedure suits one person. Those decisions belong with a licensed clinician who can examine you.

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For clinicians

Medicines to bring to your team: GLP-1 drugs, SGLT2 drugs, blood thinners and supplements

What labels and guidelines say about the medicines anesthesia and surgical teams most need to know about. The plan for each one is set by your team.

8 minute read, written for clinicians12 sources, each checked word for wordLibrary checked October 18, 2026

A hand reaching into a weekly pill organizer

This is the clinician view. It keeps every sentence of the plain guide and adds, for each section, the study design and citations of its sources, exact figures, and label wording quoted whole, marked For clinicians. Every added sentence is cited and checked like the rest. Back to plain language.

In short

  • The Ozempic label tells patients to inform their healthcare providers before any planned surgery or procedure.Official text1
  • A 2024 multisociety guidance says most people at low risk can continue GLP-1 drugs before elective surgery. Those at highest risk of stomach side effects may follow a liquid diet for 24 hours.E2Good2
  • Blood thinner plans are set for each procedure; a chest physicians' guideline strongly recommends against heparin bridging in atrial fibrillation.E2Good3
  • Garlic, ginkgo and ginseng can affect bleeding, and kava and valerian can deepen sedation.Review4

How sure each claim is:E1StrongE2GoodOfficial textReviewWhat the grades meanUnderlined words open a definition

Why this list matters

Bring a complete list of everything you take, including over-the-counter medicines, vitamins and supplements, to your surgical and anesthesia teams. They decide what to continue, pause or adjust, and when. Nothing on this page is a reason to stop or change a medicine on your own.

A review of herbal medicines and surgery advises that physicians explicitly ask about and document herbal medicine use before surgery.Review4

The evidence in this section (1 source)
SourceDesignGradeCitations (NIH iCite)
4 Ang-Lee MK, JAMA, 2001Expert reviewReview536 (RCR 19.79)

GLP-1 drugs (semaglutide, liraglutide, tirzepatide and others)

The Ozempic label reports rare cases of pulmonary aspiration in people taking GLP-1 receptor agonists. These people had food left in the stomach despite following fasting instructions before surgery or deep sedation.Official text1

One study used stomach ultrasound before anesthesia. In it, 56% of people taking a GLP-1 drug had increased stomach contents, against 19% of those not taking one.E2Good5

The authors suggested that standard fasting times may be inadequate for this group.E2Good5

A large cohort study of upper endoscopy found no increased aspiration risk with GLP-1 drugs compared with SGLT2 drugs. But more procedures had to be stopped, possibly because of food left in the stomach.E2Good6

A 2024 multisociety guidance says patients at low risk of delayed stomach emptying having elective surgery can continue GLP-1 drugs. It also says that people early in treatment, while the dose is being increased, are more likely to have delayed emptying.E2Good2

Some people are at the highest risk of significant stomach side effects. For them, the guidance describes a liquid diet for 24 hours before the procedure or other measures, depending on the circumstances.E2Good2

For clinicians

The Ozempic label, quoted as written:

There have been rare postmarketing reports of pulmonary aspiration in patients receiving GLP-1 receptor agonists undergoing elective surgeries or procedures requiring general anesthesia or deep sedation who had residual gastric contents despite reported adherence to preoperative fasting recommendations.

Quoted word for word from OZEMPIC (semaglutide) injection, Prescribing Information Official text1

Sen's study enrolled 124 participants (median age 56 years; 60% female). Increased residual gastric content was found in 35 of 62 taking a GLP-1 receptor agonist and 12 of 62 not taking one.E2Good5

GLP-1 receptor agonist use was independently associated with increased residual gastric content on preprocedural gastric ultrasound.E2Good5

Alkabbani's comparative cohort study of upper endoscopy, quoted as written:

In this comparative cohort study, no increased risk of pulmonary aspiration during upper gastrointestinal endoscopy was observed among adults with type 2 diabetes using GLP-1 receptor agonists compared with SGLT-2 inhibitors within 30 days of the procedure; however, GLP-1 receptor agonists were associated with a higher risk of discontinuation of endoscopy, possibly owing to a higher risk of retained gastric content.

Quoted word for word from Glucagon-like peptide-1 receptor agonists before upper gastrointestinal endoscopy and risk of pulmonary aspiration or discontinuation of procedure: cohort study E2Good6
The evidence in this section (4 sources)
SourceDesignGradeCitations (NIH iCite)
1 Novo Nordisk, 2026FDA labelOfficial textNot tracked
5 Sen S, JAMA Surg, 2024Observational studyE2Good163 (RCR 33.17)
6 Alkabbani W, BMJ, 2024Observational studyE2Good50 (RCR 9.64)
2 American Society of Anesthesiologists, 2024Consensus statementE2GoodNot tracked

SGLT2 drugs (empagliflozin and others)

The Jardiance label gives this instruction to prescribers, quoted as written:

Withhold JARDIANCE for at least 3 days, if possible, prior to surgery or procedures associated with prolonged fasting. Resume JARDIANCE when the patient is clinically stable and has resumed oral intake [see Warnings and Precautions (5.1) and Clinical Pharmacology (12.2)].

Quoted word for word from JARDIANCE (empagliflozin) tablets, Prescribing Information Official text7

Your prescriber and surgical team decide whether and when this applies to you.

The evidence in this section (1 source)
SourceDesignGradeCitations (NIH iCite)
7 Boehringer Ingelheim Pharmaceuticals, Inc., 2026FDA labelOfficial textNot tracked

Blood thinners and aspirin

A 2022 guideline from the American College of Chest Physicians made 44 recommendations on blood thinners around surgery. Two are strong: against heparin bridging in people with atrial fibrillation, and for continuing warfarin-type drugs during pacemaker or defibrillator implantation.E2Good3

The guideline has separate recommendations for minor procedures: dental, skin, eye, pacemaker and endoscopic procedures.E2Good3

In the BRIDGE trial, people with atrial fibrillation whose warfarin was paused for surgery did as well without bridging injections as with them for preventing clots. They also had less major bleeding (1.3% against 3.2%).E1Strong8

The PAUSE study used a standard plan for pausing direct oral anticoagulants, without bridging or blood tests. The plan was linked with low rates of major bleeding and stroke-type clots.E2Good9

In the POISE-2 trial, aspirin given before and after noncardiac surgery did not reduce death or heart attack but increased major bleeding.E1Strong10

For spinal, epidural and nerve block anesthesia, a regional anesthesia society notes that bleeding complications are extremely rare. It proposes conservative times for pausing blood thinners before these blocks.E2Good11

For clinicians

The 2022 CHEST guideline's summary, quoted as written:

A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation.

Quoted word for word from Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline E2Good3

In BRIDGE, a randomized trial, arterial thromboembolism occurred in 0.4% without bridging and 0.3% with bridging (risk difference 0.1 percentage points; 95% CI -0.6 to 0.8; P=0.01 for noninferiority).E1Strong8

Major bleeding occurred in 1.3% without bridging and 3.2% with bridging (relative risk 0.41; 95% CI 0.20 to 0.78; P=0.005 for superiority).E1Strong8

The ASRA guideline's approach to neuraxial and deep blocks, quoted as written:

It is impossible to perform large, randomized controlled trials evaluating a complication this rare; therefore, where the evidence is limited, the authors continue to maintain an 'antihemorrhagic' approach focused on patient safety and have proposed conservative times for the interruption of therapy prior to neural blockade.

Quoted word for word from Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (fifth edition) E2Good11
The evidence in this section (5 sources)
SourceDesignGradeCitations (NIH iCite)
3 Douketis JD, Chest, 2022GuidelineE2Good331 (RCR 35.35)
8 Douketis JD, N Engl J Med, 2015Randomized trialE1Strong817 (RCR 34.98)
9 Douketis JD, JAMA Intern Med, 2019Observational studyE2Good409 (RCR 23.93)
10 Devereaux PJ, N Engl J Med, 2014Randomized trialE1Strong650 (RCR 25.12)
11 Kopp SL, Reg Anesth Pain Med, 2025GuidelineE2Good77 (RCR 29.3)

Herbal medicines and supplements

A review in JAMA describes bleeding from garlic, ginkgo and ginseng, and heart and blood pressure instability from ephedra. It describes low blood sugar from ginseng and stronger sedation from kava and valerian. It also describes faster breakdown of many surgical drugs caused by St John's wort.Review4

For clinicians

The JAMA review, quoted as written:

Direct effects include bleeding from garlic, ginkgo, and ginseng; cardiovascular instability from ephedra; and hypoglycemia from ginseng. Pharmacodynamic herb-drug interactions include potentiation of the sedative effect of anesthetics by kava and valerian. Pharmacokinetic herb-drug interactions include increased metabolism of many drugs used in the perioperative period by St John's wort.

Quoted word for word from Herbal medicines and perioperative care Review4
The evidence in this section (1 source)
SourceDesignGradeCitations (NIH iCite)
4 Ang-Lee MK, JAMA, 2001Expert reviewReview536 (RCR 19.79)

Smoking

Pooling six randomized trials, stopping smoking before surgery reduced complications by 41%. Each week of not smoking increased the effect by 19%, and stopping for at least 4 weeks had a larger effect.E1Strong12

For clinicians

Mills' meta-analysis pooled 6 randomized trials: relative risk reduction for postoperative complications 41% (95% CI 15 to 59, P = .01). Each week of cessation increased the effect by 19%, and trials of at least 4 weeks' cessation had a significantly larger effect than shorter trials (P = .04).E1Strong12

The authors concluded that longer periods of smoking cessation decrease the incidence of postoperative complications.E1Strong12

The evidence in this section (1 source)
SourceDesignGradeCitations (NIH iCite)
12 Mills E, Am J Med, 2011Meta-analysisE1Strong396 (RCR 15.49)

Questions you might bring to your anesthesia team

  1. Here is my full list of medicines and supplements: which should I continue, pause or adjust, and when?
  2. I take a GLP-1 drug: does that change my fasting plan or my procedure day?
  3. I take an SGLT2 drug: what is the plan for it?
  4. I take a blood thinner or aspirin: who decides the plan, and do I need bridging?
  5. Is there anything to start before surgery, such as quitting smoking support?

Every claim in this guide was written from its sources and checked against them word for word. Its clinical review by Dr. Recio, a practicing nurse anesthesiologist (CRNA), is pending. This line changes when the review is done.

Sources

Each source opens on PubMed, DailyMed or the publisher's page. Under each one are the exact words from it that this page relies on, copied word for word and checked against the original.

  1. OZEMPIC (semaglutide) injection, Prescribing Information. Novo Nordisk, 2026. Official text FDA label
    The words this page rests on
    Instruct patients to inform healthcare providers prior to any planned surgeries or procedures if they are taking OZEMPIC.
    There have been rare postmarketing reports of pulmonary aspiration in patients receiving GLP-1 receptor agonists undergoing elective surgeries or procedures requiring general anesthesia or deep sedation who had residual gastric contents despite reported adherence to preoperative fasting recommendations.
  2. Most Patients Can Continue Diabetes, Weight Loss GLP-1 Drugs Before Surgery, Those at Highest Risk for GI Problems Should Follow Liquid Diet Before Procedure (ASA news release on the multisociety clinical practice guidance). American Society of Anesthesiologists, 2024. E2Good Consensus statement
    The words this page rests on
    Patients at low risk for delayed stomach emptying who are having elective surgery can continue to take their GLP-1 drugs, the guidance says.
    Patients at the highest risk for significant gastrointestinal (GI) side effects should follow a liquid diet for 24 hours before the procedure or other measures, depending on the specific circumstances.
    Patients in the escalation phase of GLP-1 drugs (early in treatment) are more likely to have delayed stomach emptying.
  3. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Douketis JD, Chest, 2022. E2Good GuidelinePMID 35964704; DOI 10.1016/j.chest.2022.07.025; cited 331 times, relative citation ratio 35.35 (NIH iCite, 2026-10-18)
    The words this page rests on
    A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation.
    There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures.
  4. Herbal medicines and perioperative care. Ang-Lee MK, JAMA, 2001. Review Expert reviewPMID 11448284; DOI 10.1001/jama.286.2.208; cited 536 times, relative citation ratio 19.79 (NIH iCite, 2026-10-18)
    The words this page rests on
    Direct effects include bleeding from garlic, ginkgo, and ginseng; cardiovascular instability from ephedra; and hypoglycemia from ginseng. Pharmacodynamic herb-drug interactions include potentiation of the sedative effect of anesthetics by kava and valerian. Pharmacokinetic herb-drug interactions include increased metabolism of many drugs used in the perioperative period by St John's wort.
    During the preoperative evaluation, physicians should explicitly elicit and document a history of herbal medication use.
  5. Glucagon-Like Peptide-1 Receptor Agonist Use and Residual Gastric Content Before Anesthesia. Sen S, JAMA Surg, 2024. E2Good Observational studyPMID 38446466; DOI 10.1001/jamasurg.2024.0111; cited 163 times, relative citation ratio 33.17 (NIH iCite, 2026-10-18)
    The words this page rests on
    Among the 124 participants (median age, 56 years [IQR, 46-65 years]; 75 [60%] female), the prevalence of increased RGC was 56% (35 of 62) in patients with GLP-1 RA use (exposure group) compared with 19% (12 of 62) in patients who were not taking a GLP-1 RA drug (control group).
    Use of a GLP-1 RA was independently associated with increased RGC on preprocedural gastric ultrasonography. The findings suggest that the preprocedural fasting duration suggested by current guidelines may be inadequate in this group of patients at increased risk of aspiration under anesthesia.
  6. Glucagon-like peptide-1 receptor agonists before upper gastrointestinal endoscopy and risk of pulmonary aspiration or discontinuation of procedure: cohort study. Alkabbani W, BMJ, 2024. E2Good Observational studyPMID 39438043; DOI 10.1136/bmj-2024-080340; cited 50 times, relative citation ratio 9.64 (NIH iCite, 2026-10-18)
    The words this page rests on
    In this comparative cohort study, no increased risk of pulmonary aspiration during upper gastrointestinal endoscopy was observed among adults with type 2 diabetes using GLP-1 receptor agonists compared with SGLT-2 inhibitors within 30 days of the procedure; however, GLP-1 receptor agonists were associated with a higher risk of discontinuation of endoscopy, possibly owing to a higher risk of retained gastric content.
  7. JARDIANCE (empagliflozin) tablets, Prescribing Information. Boehringer Ingelheim Pharmaceuticals, Inc., 2026. Official text FDA label
    The words this page rests on
    Withhold JARDIANCE for at least 3 days, if possible, prior to surgery or procedures associated with prolonged fasting. Resume JARDIANCE when the patient is clinically stable and has resumed oral intake [see Warnings and Precautions (5.1) and Clinical Pharmacology (12.2)].
  8. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. Douketis JD, N Engl J Med, 2015. E1Strong Randomized trialPMID 26095867; DOI 10.1056/NEJMoa1501035; cited 817 times, relative citation ratio 34.98 (NIH iCite, 2026-10-18)
    The words this page rests on
    In patients with atrial fibrillation who had warfarin treatment interrupted for an elective operation or other elective invasive procedure, forgoing bridging anticoagulation was noninferior to perioperative bridging with low-molecular-weight heparin for the prevention of arterial thromboembolism and decreased the risk of major bleeding.
    The incidence of arterial thromboembolism was 0.4% in the no-bridging group and 0.3% in the bridging group (risk difference, 0.1 percentage points; 95% confidence interval [CI], -0.6 to 0.8; P=0.01 for noninferiority). The incidence of major bleeding was 1.3% in the no-bridging group and 3.2% in the bridging group (relative risk, 0.41; 95% CI, 0.20 to 0.78; P=0.005 for superiority).
  9. Perioperative Management of Patients With Atrial Fibrillation Receiving a Direct Oral Anticoagulant. Douketis JD, JAMA Intern Med, 2019. E2Good Observational studyPMID 31380891; DOI 10.1001/jamainternmed.2019.2431; cited 409 times, relative citation ratio 23.93 (NIH iCite, 2026-10-18)
    The words this page rests on
    In this study, patients with AF who had DOAC therapy interruption for elective surgery or procedure, a perioperative management strategy without heparin bridging or coagulation function testing was associated with low rates of major bleeding and arterial thromboembolism.
  10. Aspirin in patients undergoing noncardiac surgery. Devereaux PJ, N Engl J Med, 2014. E1Strong Randomized trialPMID 24679062; DOI 10.1056/NEJMoa1401105; cited 650 times, relative citation ratio 25.12 (NIH iCite, 2026-10-18)
    The words this page rests on
    Administration of aspirin before surgery and throughout the early postsurgical period had no significant effect on the rate of a composite of death or nonfatal myocardial infarction but increased the risk of major bleeding.
  11. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (fifth edition). Kopp SL, Reg Anesth Pain Med, 2025. E2Good GuidelinePMID 39880411; DOI 10.1136/rapm-2024-105766; cited 77 times, relative citation ratio 29.3 (NIH iCite, 2026-10-18)
    The words this page rests on
    Hemorrhagic complications associated with regional anesthesia are extremely rare.
    It is impossible to perform large, randomized controlled trials evaluating a complication this rare; therefore, where the evidence is limited, the authors continue to maintain an 'antihemorrhagic' approach focused on patient safety and have proposed conservative times for the interruption of therapy prior to neural blockade.
  12. Smoking cessation reduces postoperative complications: a systematic review and meta-analysis. Mills E, Am J Med, 2011. E1Strong Meta-analysisPMID 21295194; DOI 10.1016/j.amjmed.2010.09.013; cited 396 times, relative citation ratio 15.49 (NIH iCite, 2026-10-18)
    The words this page rests on
    We pooled the 6 randomized trials and demonstrated a relative risk reduction of 41% (95% confidence interval [CI], 15-59, P = .01) for prevention of postoperative complications. We found that each week of cessation increases the magnitude of effect by 19%. Trials of at least 4 weeks' smoking cessation had a significantly larger treatment effect than shorter trials (P = .04).
    Longer periods of smoking cessation decrease the incidence of postoperative complications.