Do GLP-1 Agonists Really Need to Be Stopped Before Endoscopy?

Continuing GLP-1 receptor agonist medications when undergoing an endoscopic procedure appeared safe in a meta-analysis.

In pooled findings from nine studies, patients undergoing endoscopy while taking GLP-1 receptor agonists had no increased risk of aspiration compared to patients not taking the medications (pooled OR 1.03, 95% CI 0.61-1.73, P=0.92), found researchers led by Violeta B. Popov, MD, PhD, of NYU Langone Health and the NY VA Harbor Health System in New York City.

But patients taking GLP-1 drugs did have a greater likelihood of retained gastric contents and of aborted upper endoscopies, Popov reported at the annual meeting of the American College of Gastroenterology.

The potential of GLP-1 receptor agonists to slow gastric emptying raised safety concerns for GI endoscopy that initially led the American Society of Anesthesiologists (ASA) to advise in 2023 that patients withhold GLP-1 injectables for 1 week and oral GLP-1 agents for 1 day prior to their procedure. But new guidelines from the ASA, the American Gastroenterological Association (AGA), and several other clinical organizations recently reversed this guidance, stating that most patients can continue GLP-1 receptor agonists (RAs) up until the day of surgery if they have a 24-hour clear liquid diet beforehand.

“There is limited evidence, or no evidence that we could find, supporting the 2023 ASA guidelines for holding GLP-1 RAs for one dose prior to endoscopy,” Popov said. “However, our data shows that patients undergoing simultaneous upper endoscopy and colonoscopy after a 24-hour clear liquid diet are not actually getting increased residual gastric contents, so our data supports the 2024 AGA clinical practice update, which recommends 24-hour clear liquid diet for patients undergoing upper endoscopy on GLP-1 RAs.”

The researchers examined all studies from MEDLINE, Embase, and Cochrane Database through October 2024 that reported on outcomes of upper endoscopy, colonoscopy, or both and included at least five participants taking GLP-1 agonists and undergoing one of those procedures. These patients were compared to those not taking GLP-1 medications or patients undergoing a 24-hour clear liquid diet prior to endoscopy.

They identified 34 articles that reported on odds or rates of aspiration, aborted esophagogastroduodenoscopy (EGD), or residual gastric content in patients taking GLP-1 agonists.

Despite finding no increased risk for aspiration with GLP-1s with endoscopy, the researchers found substantially higher odds of an aborted EGD for patients taking GLP-1 medications than for those not taking them (pooled OR 5.19, 95% CI 3.5-7.7).

The event rate of retained gastric contents with upper endoscopies was 11.9% in patients taking GLP-1s compared with 3.4% in patients not taking GLP-1s, resulting in greater odds of residual gastric content with GLP-1 medications (OR 4.38, 95% CI 3.14-6.09).

“Obviously GLP-1 RAs increase the risk for residual gastric contents, so potentially that would increase the risk of aspiration and definitely is more likely to lead to aborted upper endoscopy,” Popov said. So they next looked at patients who underwent a 24-hour clear liquid diet and bowel prep for a colonoscopy that would be done at the same time as an upper endoscopy.

The pooled event rate for residual gastric content in these patients was 0.047 (95% CI 0.038-0.059), “very similar to what we saw for patients who were not on GLP-1 RAs,” Popov said.

Then they looked at the studies that compared residual gastric contents in patients taking GLP-1s who had an upper endoscopy versus those taking GLP-1s who had an upper endoscopy and colonoscopy. The patients only undergoing an EGD had numerically higher odds of residual gastric content than those undergoing both procedures together (OR 4.62, 95% 0.25-86.23).

When the researchers compared patients not taking GLP-1s undergoing upper endoscopy and those taking GLP-1s undergoing both EGD and colonoscopy, it was the patients not taking GLP-1s and undergoing EGD who had a greater likelihood of residual gastric contents (OR 1.74, 95% CI 1.23-2.46), “again showing that the clear liquid diet was protective,” Popov said.