Key takeaways:

• Hospitalists will increasingly have to manage inpatients taking GLP-1s.
• Because many medications can cause weight gain, doctors should consider more weight-neutral alternatives.
• Medical societies and hospitals are weighing in on periprocedural concerns in patients taking GLP-1s who need procedures or surgeries.

THE BLOCKBUSTER GLP-1 receptor agonists are a transformative class of medications increasingly tied to better outcomes across a variety of conditions and organ systems, not just in patients with obesity and type 2 diabetes.

That’s according to two internists who work closely with hospitalized patients who take GLP-1s. They presented a rapid clinical update Webinar in May 2025 hosted by the Society of Hospital Medicine.

Both experts—Marci Laudenslager, MD, MHS, an obesity medicine specialist at Baltimore’s Johns Hopkins, and Lily Ackermann, MD, ScM, a hospitalist with a background in endocrinology with Thomas Jefferson University in Philadelphia—pointed out that hospitalists probably won’t be the initial prescribing clinician for these medications. Nor should they be.

“I would not recommend starting a GLP-1 in the hospital.”

Lily Ackermann, MD, ScM
Thomas Jefferson University

“I think it’s best to refer prescribing out to a weight-loss specialist or endocrinologist,” said Dr. Ackermann. “You want someone who can monitor patients’ side effects and have a longitudinal relationship with them.” While doctors in the hospital have earlier-generation weight-loss drugs they can prescribe, “I would not recommend starting a GLP-1 in the hospital.”

But that doesn’t mean that hospitalists won’t continue to see a growing number of patients on GLP-1s in the hospital. As a result, hospitalists will increasingly have to take these medicines into account, not only when patients are undergoing procedures in the hospital, but also when choosing other medications to prescribe.

“Life-changing” medicines

Obesity, said Dr. Laudenslager, is a chronic metabolic disease with highly complex pathophysiology—”and we are programmed to regain the weight we lose with lifestyle measures.” That is why, she added, anti-obesity medications are such an important strategy in long-term management. Moreover, because obesity is a chronic disease, “anti-obesity medications should be continued long term, and we can’t stop these medications, just like we wouldn’t stop those for diabetes or hypertension.”

All anti-obesity medications, even the earlier generation of these drugs—which include orlistat, phentermine, phentermine/topiramate (Qsymia) and naltrexone/bupropion (Contrave)—cause clinically significant weight loss. “By ‘clinically significant,’ I mean around five to 10% of patients’ weight,” Dr. Laudenslager said.

As for GLP-1s, semaglutide (Ozempic, Wegovy, Rybelsus) at its highest dose can produce about 15% body weight loss, Dr. Laudenslager pointed out, while tirzepatide (Mounjaro, Zepbound) can deliver body weight loss of between 20% and 22%. Those percentages, she said, “are knocking on the door of the efficacy we typically achieve only with metabolic surgery. These medications are truly life-changing for many patients.”

“Medications are the first thing I think about when I’m talking to a patient who is experiencing binge eating or feeling a loss of control with eating.”

Marci Laudenslager, MD, MHS
Johns Hopkins

 

They also, she added, are skyrocketing in efficacy. GLP-1s suppress the appetite, increase resting energy expenditure, favor the use of stored fat as energy and reduce pro-inflammatory visceral fat.

These therapies also modulate dopamine signaling, Dr. Laudenslager continued. “GLP-1s work on reward pathways in the brain, which is why these medicines are being explored in alcohol use and substance use disorders.” They also have an impact on cardiac remodeling, reduce albuminuria, improve insulin sensitivity, reduce neuroinflammation—and the list goes on.

GLP-1s in medical admissions

Medical patients being admitted often worry about going off GLP-1s in the hospital, concerned they will rebound and gain weight. Still, “to be on the safe side,” Dr. Ackermann said, “I think it’s reasonable to hold these medications in the hospital. Patients coming in are usually sick, and many of them may need procedures.”

There’s no need to taper hospitalized patients off of GLP-1s, said Dr. Laudenslager. “But if someone is off their medication in the hospital and they were on a higher dose, they usually cannot just restart the medication at that higher dose.” After patients have missed two doses, “we usually need to ramp them back up again from the lowest dose,” she added, “just to make sure they don’t have GI side effects.”

At the same time, hospital stays are often the time patients have new medications prescribed for them. “If you’re thinking about how you can impact the lives of patients with obesity, their medication list is where you should start,” Dr. Laudenslager said. Beta-blockers, for instance, “notoriously cause weight gain through a number of mechanisms.” Alternatives include ACE inhibitors, ARBs and CCBs, with “carvedilol typically being the most weight-neutral beta-blocker.”

Corticosteroids impair glucose tolerance; NSAIDs are a better choice, if appropriate. Insulin has tremendous anabolic effects, although “basal insulin may cause less weight gain than combo or pre-mixed.”

Both SSRIs and atypical antipsychotics cause food cravings, as do tricyclic antidepressants (TCAs). Instead of an SSRI or a TCA, bupropion is a good alternative.

“Medications are the first thing I think about when I’m talking to a patient who is experiencing binge eating or feeling a loss of control with eating,” she said. “I look at their medication list, and a lot of times, they are on a medication that has affected their appetite in a negative way.” The goal then becomes, she added, to transition them to a medication that is more weight-neutral or to start them on an anti-obesity medicine to offset the weight gain happening from the drug that’s been prescribed.

“If I have to start someone on a medicine that causes weight gain,” Dr. Laudenslager pointed out, “I may also start them on metformin to offset some of that weight gain.” Starting patients on an FDA-approved or off-label anti-obesity medication—along with considering metabolic surgery—is also her strategy for patients whose BMI is so high that they can’t safely be discharged from the hospital.

GLP-1s and procedures

Then there’s the critical issue of what to do when patients taking these drugs come in for procedures. Both medical societies and hospitals are now tackling periprocedural concerns.

Given how much more slowly patients on these medications empty their stomachs of food, case reports have detailed regurgitation and aspiration during surgeries and procedures. So how long before a scheduled procedure should patients stop taking these medications—if they should stop them at all?

Despite a flurry of recent guidelines, “there’s no evidence to suggest optimal fasting duration,” Dr. Ackermann explained. In guidance released in 2023, the American Society of Anesthesiologists recommended holding a dose on the day of surgery for those taking a daily dose—and a week prior for those on weekly dosing. (If you have to hold a GLP-1 agonist for more than the dosing schedule in patients with diabetes, get an endocrine consult for an alternative diabetes treatment.)

But that consensus statement also noted that if a patient’s GLP-1 wasn’t held or if the patient is having abdominal symptoms, “you should proceed with a gastric ultrasound,” Dr. Ackermann added. “If that’s inconclusive or not available, you can either delay the procedure or consider using full-stomach precautions.” Those precautions include rapid-sequence intubation, nasogastric aspiration and a cuffed endotracheal tube to prevent aspiration.

The American Gastroenterology Society weighed in with its own consensus statement, noting that there was no hard evidence of increased aspiration or pneumonia risk during procedures for patients taking GLP-1s—and no data to support stopping GLP-1s.

Instead, the statement supported a more individualized approach with a scheduled endoscopy if patients have no symptoms such as nausea, vomiting, dyspepsia or abdominal distention. The guidance also recommends that patients have a liquid diet 24 hours before a procedure and that proceduralists use full-stomach precautions if delaying endoscopy would be harmful. However, not all outpatient endoscopy suites may be equipped to do that.

Guidance released in October 2024 from multiple societies recommended an individualized approach to the decision of holding GLP-1s and using shared decision-making to assess a patient’s procedural risk.

That includes considering risk factors, escalating doses, symptoms and other medical conditions that can worsen gastroparesis. They guidelines also recommend mitigating risk with measures such as a liquid diet, full-stomach precautions and modifications to the anesthesia plan.

Those recommendations were echoed in another consensus statement, this one from the Society for Perioperative Assessment and Quality Improvement in May 2025 in the British Journal of Anaesthesia.

Patients without significant GI symptoms—such as severe nausea, vomiting and an inability to tolerate oral intake—can continue their GLP-1s perioperatively without interruption. But they should follow some diet modifications, including a liquid diet for 24 hours before the procedure.

“More studies are needed,” Dr. Ackermann said. “But ask patients about their symptoms, consider gastric ultrasound if it’s available and use a liquid diet for 24 hours prior.” While many guidelines recommend holding GLP-1s periprocedurally, “speak to your proceduralists and anesthesiologists, and follow your anesthesia and institution guidelines,” she advised. “We really don’t yet know.”

Coverage barriers

The cost of GLP-1s is, of course, the biggest barrier to care, particularly when these medications are used off-label.

“GLP-1 coverage is a common struggle for patients,” said Dr. Laudenslager. Prior approvals are also “a real challenge. A lot of plans require a prior approval for each dose, and insurance plans are making access really difficult.” Some pharmacies offer discounts, and some clinicians prescribe 1 mg or 2 mg Ozempic pens to save patients money.

“You can prescribe a high dose pen, then have patients count the clicks that the pen dial makes to deliver a much lower dose,” she said. “That will make one pen last two to four months instead of just one.”

Right now, Dr. Laudenslager said, injectable medications are typically more effective than oral therapies—but “we’re getting there. I think we will see greater efficacy with oral medications that target more than one metabolism hormone.” That should be really important, she added, because “I’m hoping oral therapies will be a more effective—and more cost-effective—strategy for patients long term.”

Phyllis Maguire has been Executive Editor of Today’s Hospitalist since 2006. Based in Bucks County, Pa., her health care interests are hospital medicine and long-term care options. She also likes zydeco, hiking, and reading memoirs and romances.

Mounting evidence for GLP-1s’ efficacy

IT REMAINS to be seen if insurers will end up covering GLP-1s for patients who have obesity but not type 2 diabetes.

What is clear is that a growing flow of studies show that GLP-1s have a substantial impact on multiple organ systems. Lily Ackermann, MD, ScM, a hospitalist with Thomas Jefferson University in Philadelphia, pointed out that renal risk reduction is one clear benefit of GLP-1s.

While data are more robust for SGLT-2 inhibitors, which are the preferred drugs to use in diabetic kidney injury, GLP-1s are recommended if SGLT-2 inhibitors can’t be used.

Published in May 2024, the FLOW trial, for instance, looked at patients with diabetes and advanced kidney disease. That study found a significant decrease in the rate of GFR decline and a significant reduction in cardiovascular-related death.

And “GLP-1s have been shown in large trials to have significant benefits not only in weight loss but in cardiovascular risk reduction,” said Dr. Ackermann. The SELECT trial, which was published in the NEJM in November 2023, tested semaglutide vs. placebo.

“What was unique about this study is that it looked at patients without diabetes, shifting the view from GLP-1s as a diabetes drug to one for heart disease,” she noted. That trial found “an impressive 20% reduction” in the incidence of cardiovascular death, MI or stroke.

More recently, the SUMMIT trial published in November 2024 looked at tirzepatide in patients with heart failure and preserved ejection fraction. That research found that the drug reduced the combined risk of worsening heart failure events and cardiovascular death in a population with obesity and preexisting cardiovascular disease.

There’s also a growing body of cardiology literature, including two studies—here and here —published in The Lancet in August 2024.

“For patients with obesity and heart failure with preserved ejection fraction, GLP-1s can improve functional capacity and heart failure stability,” Dr. Ackermann said. More data are needed, however, for patients with heart failure and reduced ejection fraction, “especially those with very low EF.”

Smaller studies also suggest that GLP-1 agonists have favorable effects in patients with metabolic-associated liver disease dysfunction and steatohepatitis, with a reduction in progression to end-stage liver disease.

Published in April 2025, the ESSENCE study is notable, Dr. Ackermann said, “because it’s a large, randomized trial with about 800 patients with MASH and fibrosis.”

While the trial is ongoing for five years, data from the first 72 weeks found a significant reduction in fibrosis, with semaglutide reversing steatohepatitis in 63% of subjects vs. 34% of those taking placebo. At the same time, more than one-third of the patients given a GLP-1 had reduced liver fibrosis.

The next step in the research, Dr. Ackermann added, will be to look beyond histology at the five-year mark and at clinical endpoints to see if fewer patients have progressed to cirrhosis.

GLP-1 Medications in Hospital Settings: What Every Clinician Needs to Know