Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are increasingly used for type 2 diabetes, obesity, and broader cardiometabolic, cardiorenal, and metabolic liver disease indications, creating new challenges for perioperative medication safety. This review summarizes current evidence on GLP-1RA-associated delayed gastric emptying and proposes a structured pharmacist-led framework for individualized perioperative risk management. GLP-1RAs may increase the likelihood of residual gastric contents during anesthesia or procedural sedation despite adherence to standard fasting recommendations. Perioperative outcome studies have not consistently shown an increased risk of aspiration pneumonia; however, these findings should be interpreted in light of the low incidence of aspiration-related events, the predominance of retrospective study designs, residual confounding, and heterogeneous definitions of residual gastric contents. We review mechanisms of delayed gastric emptying, treatment- and patient-related risk modifiers, perioperative clinical evidence, areas of agreement and divergence among major guidance statements, gastric ultrasonography as a selective risk-mitigation tool, and medication-safety issues beyond aspiration, including oral drug absorption and postoperative resumption. Because perioperative GLP-1RA decisions require accurate medication history, last-dose verification, symptom assessment, evaluation of glycemic consequences of drug interruption, coordination with anesthesia and surgical teams, and safe postoperative restart planning, pharmacists are well positioned to support this process. The proposed pharmacist-led pathway provides a structured approach to GLP-1RA medication verification, gastrointestinal symptom screening, risk phenotyping, multidisciplinary escalation, day-of-surgery reassessment, postoperative restart planning, patient education, and documentation. Perioperative GLP-1RA management should not rely on routine discontinuation alone, but should integrate treatment phase, dose escalation, gastrointestinal symptoms, comorbid motility disorders, procedural urgency, anesthetic risk, oral medication considerations, and the metabolic consequences of withholding therapy. This pathway represents a structured implementation framework informed by current evidence and guidance; prospective evaluation in real-world perioperative settings is needed.
