A clear liquid diet prior to GI endoscopy may be ‘more important’ than holding GLP-1RAs
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Key takeaways:
- GLP-1RA use prior to upper endoscopy was linked to increased risk for retained gastric contents.
- A 24-hour clear liquid diet prior to the procedure may mitigate this outcome vs. holding GLP-1RAs.
PHILADELPHIA — Although glucagon-like peptide-1 receptor agonist use may increase the risk for retained gastric contents in those undergoing endoscopic procedures, a 24-hour clear liquid diet may be “protective” vs. holding the medication.
“Last year, the American Society of Anesthesiology recommended holding GLP-1RAs before gastrointestinal procedures, mainly based on descriptive evidence [and] case reports of aspiration occurring in patients on GLP1-RAs,” Violeta B. Popov, MD, PhD, FACG, director of bariatric endoscopy at NY VA Harbor Healthcare System and associate professor at NYU Grossman School of Medicine, told Healio. “It started affecting all our practices, with our colleagues from anesthesia canceling procedures.”
She continued: “Additionally, this recommendation has a downside for our patients with diabetes: If they hold their medication for a week, they run the risk of developing hyperglycemia.”
To evaluate the risk for aspiration and other safety concerns associated with GLP-1RAs, Popov and colleagues performed a systematic review and meta-analysis of research that included outcomes of upper endoscopy and colonoscopy among patients using GLP-1RAs. Patients who were not on GLP-1RAs and those who underwent a 24-hour clear liquid diet before a procedure were included for comparison.
The researchers searched MEDLINE, Embase and Cochrane databases through October 2024 and screened 340 records, of which 34 were included in analysis. The cut-off date used in most studies to define GLP-1RA user and nonuser cohorts was June 2023, when the ASA recommendations were published.
The primary outcome was OR of aspiration/aspiration pneumonia, while secondary outcomes included pooled rates and ORs of aborted esophagogastroduodenoscopy (EGD) and retained gastric contents.
According to late-breaking data presented at the ACG Annual Scientific Meeting, use of GLP-1RAs did not increase the risk for aspiration after EGD (OR = 1.03; 95% CI, 0.61-1.73), with aspiration occurring in 0.3% of GLP-1RA users and 0.23% of nonusers. However, the risk for aborted EGD was higher among GLP-1RA users (OR = 5.19; 95% CI, 3.5-7.7), with aborted EGD occurring in 1.9% of GLP-1RA users vs. 0.4% of nonusers.
“GLP-1RA use is not associated with risk of aspiration in patients who could not hold the medications prior to upper endoscopy,” Popov said. “Having said that, aspiration is an extremely rare event in gastroenterology, and usually even if there is food retained in the stomach, the gastroenterologist and the anesthesiologist will immediately take measures to prevent this from happening — by aborting the procedure or intubating the patient if necessary.”
Further, Popov and colleagues reported that GLP-1RA users were more likely to have retained gastric contents (OR = 4.38; 95% CI, 3.14-6.09), with rates of 11.9% in GLP-1RA users vs. 3.4% in nonusers. In patients who underwent both EGD and colonoscopy, the rate of retained gastric contents was 5.5%.
“We looked at patients who had simultaneous upper endoscopy and colonoscopy [and] when you do that, patients usually undergo a 24-hour period liquid diet,” Popov said. “We found that their risk of retained gastric contents was lower than the patients who had an upper endoscopy and did not take GLP-1RAs.”
Therefore, she noted, although GLP-1RAs may increase the risk for retained gastric contents, a clear liquid diet prior to a procedure may be “protective of developing that complication or adverse event” and is “more important than holding the medication.”
“We feel that the 2023 American Society of Anesthesiology recommendations need to be updated,” Popov told Healio. “This was done in good faith, based on the data available at the time, but they do need to change to a more updated recommendation that is not necessarily holding the medication, but rather advising patients to undergo a clear liquid diet the day before. I wouldn’t necessarily advocate for canceling procedures even if the patient did not follow any of these recommendations.”