Jury still out on holding GLP-1s prior to endoscopy as new research continues to emerge

Glucagon-like peptide-1 receptor agonist use for obesity management continues to rise, but not without concerns for use during elective surgery – uncertainty remains over whether halting them beforehand is the safest option for patients.

In June 2023, the American Society of Anesthesiologists recommended holding GLP-1s at least 1 week prior to any elective surgery that required sedation due to potential complications, such as aspiration and retained gastric contents. This fueled a war between anesthesiologists and the gastroenterologists who perform endoscopic procedures.

The GI societies opposed the guidance and felt strongly that there are not enough concrete data to back claims of complications arising from GLP-1 use before endoscopy. The AGA also released guidance suggesting a 24-hour liquid diet prior to an endoscopic procedure, rather than halting GLP-1s.

Several studies have since emerged showing that use of GLP-1s before endoscopy may increase aspiration pneumonia or retained gastric content; however, there are still data that contradict these findings. A recent study has shown that holding GLP-1s may not be the best option but rather confirms that the AGA’s suggestion of a 24-hour clear liquid diet may be more effective. Another study showed prolonged fasting could also be an optimal option.

Healio continues to closely follow updates on GLP-1s, reporting on news that broke headlines and sitting down with experts to get their insights on the ongoing turf war and what’s to come. Want to see what you missed? Healio recaps the latest news in gastroenterology on GLP-1s and whether there will soon be a verdict on the drug’s place in the endoscopy suite.

A clear liquid diet prior to GI endoscopy may be ‘more important’ than holding GLP-1s

PHILADELPHIA — Although GLP-1s 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.” Read more.

GIs clash with GLP-1 restrictions for endoscopy, but ‘anesthesiologists have final say’

At the insistence of its members, the ASA recommended halting GLP-1s at least 1 week prior to any elective surgery that requires sedation.

However, this decision has placed anesthesiologists at odds with gastroenterologists performing endoscopic procedures, who maintain that there is sparse available evidence to back claims of potential complications and that this overly conservative measure will only disrupt patient care.

“The overarching concern for all gastroenterologists is delaying care and canceling procedures unnecessarily because of these recommendations,” Jennifer Phan, MD, medical director at Hoag Advanced Endoscopy Center in Irvine, California, and director of bariatric endoscopy at Hoag Digestive Health Institute, told Healio Gastroenterology. “We know time to endoscopy is important, even though they are elective procedures. Patients take time off work, and they prep for certain procedures. Any delay because of an unvalidated recommendation is a concern for all parties — patients and physicians included.” Read more.

Research needed to create ‘robust, conclusive’ evidence to manage preprocedural GLP-1 use

The use of GLP-1s exponentially increased in recent years for treating diabetes and obesity, with benefits also observed in other cardiometabolic syndromes.

However, digestive adverse effects such as nausea and vomiting are commonly reported. GLP-1RAs are an incretin hormone mimetic and contribute to gastrointestinal dysmotility, including delayed gastric emptying. Consequently, this has raised concerns regarding the potential increase in risk for respiratory complications for GLP-1 users undergoing procedural sedation. Read more.

‘No strong evidence’ to support discontinuation of GLP-1s prior to upper endoscopy

Although GLP-1s use prior to upper endoscopy was linked to a higher rate of retained gastric contents, evidence supports prolonged fasting as the “optimal approach” rather than routine discontinuation.

“Despite limited available data, the American Society of Anesthesiologists has recently issued consensus-based perioperative guidance suggesting that GLP-1s should be withheld prior to the procedure or surgery, regardless of the indication, dose or the type of procedure/surgery,” Antonio Facciorusso, MD, PhD, of the department of medical and surgical sciences at the University of Foggia in Italy, and colleagues wrote in Clinical Gastroenterology and Hepatology. Read more.

Holding GLP-1s before endoscopy ‘is justified’ to reduce risk for aspiration pneumonia

GLP-1s 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 GLP-1s 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-1s before endoscopic procedures and recommended an individualized approach for these patients.” Read more.

GLP-1s linked to notably higher rate of retained gastric contents during upper endoscopy

More than 9% of patients on GLP-1s who underwent esophagogastroduodenoscopy had retained gastric contents, although the risk for aspiration remained low, according to study results.

Further, same-day colonoscopy was reported to reduce retained gastric contents, supporting the AGA’s recent clinical practice update that recommends implementation of a liquid diet the day before endoscopy, rather than holding medication among patients at average risk for aspiration. Read more.

AGA opposes holding GLP-1 agonists for endoscopy without ‘high-level published evidence’

Updated AGA clinical practice guidelines reiterated the society’s stance that there is little data to support the recommendation that all patients should stop GLP-1s 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. Read more.

GI societies: ‘Little or no data’ linking GLP-1 agonists to safety issues during endoscopy

In response to safety concerns surrounding sedation for patients prescribed GLP-1s, the AGA, AASLD, ACG, ASGE and NASPGHAN encourage gastroenterologists to follow “best practices” for endoscopy procedures.

The use of GLP-1RAs for diabetes and weight loss management — including semaglutide (Ozempic/Rybelsus/Wegovy, Novo Nordisk), tirzepatide (Mounjaro, Lilly), exenatide (Byetta, AstraZeneca), liraglutide (Saxenda, Novo Nordisk), albiglutide (Tanzeum, GSK), dulaglutide (Trulicity, Lilly) and lixisenatide (Adlyxin, Sanofi) — have been linked to adverse GI events such as abdominal pain, constipation, diarrhea, nausea and vomiting. Read more.