AGA opposes holding GLP-1 agonists for endoscopy without ‘high-level published evidence’
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Key takeaways:
- AGA counters anesthesia guidance on GLP-1 agonists for endoscopy; based on “expert opinion,” not evidence.
- Anesthesia guidance fails to consider “potential harm” of holding GLP-1 agonist doses.
Updated AGA clinical practice guidelines reiterated the society’s stance that there is little data to support the recommendation that all patients should stop glucagon-like peptide-1 receptor agonists prior to elective endoscopy procedures.
This guidance “was necessary to provide clinical perspective” for the consensus-based perioperative guidance from the American Society of Anesthesiologists (ASA), which recommended that GLP-1 agonists be discontinued before any endoscopy procedures, Andrew Y. Wang, MD, AGAF, FACG, FJGES, FASGE, professor of medicine in the division of gastroenterology and hepatology at the University of Virginia, told Healio.
“[The ASA guidance] was being used by anesthesia providers to cancel or postpone endoscopic procedures in patients taking GLP-1 agonists who did not stop this medication prior to their procedures,” Wang said. “Anesthesia providers were not advised to consider the indication for GLP-1 RA or the potential harm of holding the medication, in particular for patients taking this class of medications to treat diabetes.”
He added: “The ASA’s suggestions were having a real impact on patient care, and many gastroenterologists and endoscopists were reaching out with questions regarding how to care for patients taking GLP-1 agonists who require endoscopic procedures.”
Therefore, Wang and colleagues all considered experts in bariatric medicine and/or
endoscopy were commissioned by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to offer guidance based on their own experiences in the field as well as recent research.
Wang and colleagues advised that clinicians “be cognizant” of a patient’s indication for GLP-1 agonists, adding that the dose, frequency, other comorbidities and medications should be noted, particularly GI side-effects such as nausea, vomiting, early satiety and dyspepsia.
“There has been increasing concern about performing endoscopic procedures, in particular upper endoscopies, on patients who are using [GLP-1 RAs] due to their effect on slowing gastric motility and the risk of aspiration of retained gastric contents in sedated patients,” researchers wrote in Clinical Gastroenterology and Hepatology.
It is unclear if skipping just one dose is “reliably adequate” for returning gastric motility to normal, Wang and colleagues noted. Patients taking GLP-1 agonists solely for weight loss can likely skip a pre-endoscopic dose with little harm, but it “should not be considered mandatory or evidence-based.” Among patients taking GLP-1 agonists for diabetes, there is not enough evidence to support holding a dose especially since having “good glycemic control” is needed before sedation/anesthesia and endoscopy.
The researchers also suggested that patients on GLP-1 agonists who follow the standard perioperative procedures, including an 8-hour solid food and a 2-hour liquid diet fast without symptoms of nausea, vomiting, dyspepsia or abdominal distention, could proceed with the endoscopy. If patients exhibit symptoms demonstrating potential “retained gastric contents,” clinicians could examine the stomach with transabdominal ultrasonography if available; however, the evidence to “support this modality in standard practice is lacking,” the researchers noted.
Further, rather than stopping the GLP-1 agonists, Wang and colleagues suggested patients be placed on a liquid diet the day prior to sedated procedures as it would be consistent with holistic management of other similar conditions.
“Clinicians gastroenterologists, endoscopists, anesthesiologists, certified registered nurse anesthetists need to treat patients as individuals when it comes to pre-procedural and peri-procedural management,” Wang told Healio. “We need to continue to use clinical judgment to care for all of our patients, and we should not over-emphasize the ASA’s perioperative guidance, which is not a clinical guideline based on high-level published evidence; rather it is largely based on expert opinion.”
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