How many days prior to elective major surgery do you recommend holding oral GLP 1 R agonist therapy?

Zero. Or, I suppose, if you're having surgery early in the morning, one.

This has gone back and forth, but the most recent guidance from the ASA (with other societies concurring) has been that most patients can continue their GLP medications as normal preoperatively, with higher-risk people being recommended to do a clear liquid diet for 24 hours preop. This makes a lot more sense than the prior guidance of holding a day for daily drugs or a week for weekly drugs, which was unphysiologic reasonin...

Oral semaglutide is dosed daily due to challenges with absorption, but once absorbed has about a 7-day half-life. Therefore, the risks due to slowing gastric emptying and potential aspiration during anesthesia could be similar to the once-weekly injectables. A holding for 10+ days recommendation makes sense if the anesthesiologists in your institution have bought into that.

The oral, small molecule, non-peptide GLP-1, or forglipron, has promising outcomes in phase 3 clinical trials. It is dosed...

Anesthesiologists are suggesting at least 1 week off once-weekly GLP1RAs or tirzepatide prior to major surgery. Guidance for daily injections is less clear. One week is probably longer than necessary, 3-5 days is probably enough. The guidelines for stopping these medications prior to surgery generally do not take into account how long a person has been taking a GLP1, or where the person is in terms of dose titration.

10+ days.