Holding GLP-1RAs before endoscopy ‘is justified’ to reduce risk for aspiration pneumonia
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Key takeaways:
- Glucagon-like peptide-1 receptor agonists were associated with a higher risk for aspiration pneumonia after endoscopy.
- Risk also was higher with propofol sedation and upper or combined upper/lower endoscopy.
Glucagon-like peptide-1 receptor agonists were linked to a significantly higher risk for aspiration pneumonia after gastrointestinal endoscopy, particularly among those undergoing upper endoscopy and propofol sedation, according to a study.
“The American Society of Anesthesiologists recently released a consensus-based guideline recommending holding [glucagon-like peptide-1 receptor agonists (GLP-1RAs)] before an endoscopic or surgical procedure to decrease the risk of aspiration,” Yee Hui Yeo, MD, a resident in the Karsh Division of Gastroenterology and Hepatology at Cedars-Sinai Medical Center in Los Angeles, and colleagues wrote in Gastroenterology. “Subsequently, the AGA released a clinical practice update that found insufficient evidence to stop GLP-1RAs before endoscopic procedures and recommended an individualized approach for these patients.”
They added, “Both societies acknowledged the paucity of data to provide firm recommendations.”
In a population-based, retrospective cohort study, Yeo and colleagues investigated the incidence and risk for aspiration pneumonia using health record data from 963,184 adults aged 21 to 70 years who underwent endoscopy between 2018 and 2020. Researchers compared outcomes among those who received GLP-1RAs vs. those who did not.
A cohort of 20,099 GLP-1RA users (mean age, 55.4 years; 56.6% women) and 778,253 non-users (mean age, 50.8 years; 52% women) met the study’s inclusion criteria and were matched for potential confounders using propensity score matching (n = 15,908 per group).
According to study results, GLP-1RA use was associated with a higher incidence rate (0.83% vs. 0.63%), as well as a “significantly higher risk” for aspiration pneumonia (HR = 1.33; 95% CI, 1.02-1.74) compared with non-users.
Researchers also reported an elevated risk among patients who had propofol-assisted endoscopies (HR = 1.49; 95% CI, 1.08-2.06) vs. those who did not (HR = 1.31; 95% CI, 0.78-2.2) and among those who underwent upper endoscopy (HR = 1.82; 95% CI, 1.27-2.6) or combined upper and lower endoscopy (HR = 2.26; 95% CI, 1.23-4.16) vs. lower endoscopy (HR = 0.56; 95% CI, 0.25-1.27).
“Holding GLP-1RAs before endoscopy may disrupt diabetes management and increase procedure cancellations, yet our findings suggest this practice is justified by the increased, albeit modest, risk of aspiration, especially in upper GI and propofol-assisted procedures,” Yeo and colleagues wrote. “Furthermore, the complex pharmacokinetics of GLP-1RAs, with uncertain timelines for gastric emptying normalization, necessitates further investigation to establish optimal drug withholding periods before endoscopies.”
Perspective
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Roberto Simons-Linares, MD, MSc
This study correlates with a recent study that found that patients who take GLP-1RAs have an increased risk for aspiration pneumonia.
The message of this study is that we need to be careful with the guidelines we develop, so as not to affect our patients’ treatments. For instance, all patients on GLP-1RAs may not need to stop their medications a month before their procedure. Also, some patients who stop their medications 1 or 2 weeks before their procedure may still experience slow gastric motility.
Some ways to optimize care for our patients may include extending a period of liquid diet for a few days before a procedure. Perhaps patients with a history of a gastric bypass anatomy, which significantly helps gastric emptying, may not necessarily need to stop GLP-1 medications, or may only need to be on a few days of liquid diet before the procedure.
The study is spot-on in showing there is a risk, but we need to be mindful of our patients who are taking medications to treat chronic diseases, such as obesity and/or diabetes. I hope guidelines can be developed with the input of anesthesiologists and endoscopists who treat patients with obesity and/or diabetes who are taking GLP-1 medications.
Reference:
- Firkins SA, et al. Clin Gastroenterol Hepatol. 2024;doi:10.1016/j.cgh.2024.03.013.
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