JULY 13, 2024
WASHINGTON—The use of glucagon-like peptide-1 receptor agonists has exploded over the past year, mainly because of their powerful anti-obesity effects, but this growth has raised concerns about potential adverse events during GI procedures. Experts discussed these concerns and presented the latest recommendations for endoscopists managing patients taking these medications at DDW 2024.
“This explosion in use has led to tremendous chaos in endoscopy—trying to navigate these new
WASHINGTON—The use of glucagon-like peptide-1 receptor agonists has exploded over the past year, mainly because of their powerful anti-obesity effects, but this growth has raised concerns about potential adverse events during GI procedures. Experts discussed these concerns and presented the latest recommendations for endoscopists managing patients taking these medications at DDW 2024.
“This explosion in use has led to tremendous chaos in endoscopy—trying to navigate these new medications in the setting of their unusual mechanisms, along with concerns about putting patients under anesthesia while they are taking them,” said Allison R. Schulman, MD, MPH, the chief of endoscopy and director of bariatric endoscopy at the University of Michigan Health, in Ann Arbor.
ASA Issued Guidance First
GLP-1s, which mimic incretins, induce glucose-dependent insulin release, stimulate satiety centers, inhibit glucagon release and diminish gastric emptying. The slowing of gastric motility and concerns about the risk for aspiration of retained gastric contents in patients undergoing endoscopy prompted the American Society of Anesthesiologists (ASA) to issue the following guidance, regardless of the drug’s indication (type 2 diabetes or weight loss) (Anesthesiology 2024;140[2]:346-348):
The ASA’s recommendation to hold GLP-1s is based on sparse evidence limited to case reports, and Harish K. Gagneja, MD, of Austin Gastroenterology, in Texas, questioned whether this is sufficient for issuing guidance. “When was the last time we had guidance based on several case reports? ... This [ASA guidance] is based on expert opinions only, and we all know that widespread implementation of expert opinions is associated with unintended consequences. … These are wishy-washy guidelines—‘suggest, consider, advise’—and they are impractical.”
Acknowledging that the ASA guidance has had an effect on endoscopy practices, Dr. Schulman said: “I’m sure everyone in this room has felt the downstream effects. We have had innumerable canceled or postponed endoscopic procedures, patients requiring general anesthesia (which adds cost, time and clinical risk), and revisions of procedure protocols, despite the lack of high-level evidence.”
Dr. Gagneja also suggested that halting these drugs in the setting of diabetes could lead to more harm than benefit, although studies to date appear to be reassuring.
The question becomes, “Is this necessary?” Dr. Schulman said. “We know that GLP-1s are associated with prolonged solid-phase emptying on gastric scintigraphy in most trials, but the clinical impact of these findings is really unclear. … Do these changes [holding medications, for example] truly mitigate the risk for aspiration or do they exacerbate other problems? Or is the truth somewhere in between?”
“The presence of food in the stomach does not equate to aspiration,” Dr. Gagneja added. “Yes, there is delayed gastric emptying, but the same thing can happen with opioids or gastroparesis,” he said, questioning why there was not similar guidance related to those scenarios.
In Dr. Gagneja’s practice, annual rates of aspiration have not changed since 2021, when semaglutide (Wegovy, Novo Nordisk) was approved for weight loss—hovering around 0.07%. “We’ve seen no change in risk of aspiration whatsoever,” he said, adding that the risk does appear to be higher in people with diabetes and hiatal hernias but not those taking GLP-1s.
“There’s insufficient published evidence for a robust guideline or systematic review,” said Dr. Schulman, who, along with Dr. Gagneja and an anesthesiologist Eric Ritter, MD, and other speakers at DDW, described conflicting results from studies (JAMA 2024;331[19]:1672-1673; Clin Gastroenterol Hepatol 2024 May 15. doi:10.1016/j.cgh.2024.04.038; J Clin Anesth 2023;87:111091; Can J Anaesth 2024 Mar 14. doi:10.1007/s12630-024-02719-z; DDW 2024, abstract Sp1253).
Risk does appear higher in patients with GI symptoms, in upper rather than lower endoscopy, in patients given propofol, and with recent initiation of the drugs, the speakers added.
“Management of these medications should be individualized as part of a shared medical decision-making process,” Dr. Schulman said.
An Anesthesiologist’s Perspective
Dr. Ritter, an assistant professor of anesthesiology at Baylor College of Medicine, in Houston, weighed in with his views during a DDW session, citing studies that show some increased risks associated with GLP-1s. “It is reasonable to hold these medications for endoscopy procedures per early guidance by the ASA. There’s strong evidence for residual gastric content in many of these patients and also some evidence that this leads to more aspiration events. There also does not appear to be evidence that hypoglycemic events occur from holding the medication.”
But he added that in his practice, he’s “a bit more liberal on this issue.” He agreed with Dr. Gagneja that other factors associated with delayed emptying have not elicited alarm from anesthesiologists, who often will “put them to sleep, put the scope down and see if there’s anything in the stomach.” He also acknowledged that colonoscopy is probably less concerning than upper endoscopy.
Dr. Ritter predicted the ASA is likely to issue more informed guidance as data start to address the “nuances” of various patient situations. He said he hopes that future studies will establish the relative differences in risk between upper and lower procedures, duration of GLP-1 use, and fasting/liquid diet as prevention.
GI Society Recommendations
In the meantime, to try to clarify the issue for endoscopists, ASGE convened a Delphi panel of 11 experts from diverse clinical backgrounds to develop best-practice recommendations (Table). The recommendations are under review and will be published soon in their entirety, according to Dr. Schulman, who chaired the panel. This effort follows a multi-society statement issued in August 2023, in which ASGE, AGA, AASLD, ACG, ASGE and NASPGHAN recommended an individualized approach, with attention to GI symptoms, indication (holding is appropriate if for weight loss), and use of a liquid diet before endoscopy, and an AGA rapid clinical practice update issued in April 2024. The Delphi panel’s recommendations provide more detailed guidance.
| Table. ASGE Delphi Panel Best-Practice Statements |
For all patients on GLP-1s undergoing endoscopy, the panel:
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For patients on GLP-1s undergoing elective endoscopies, the panel:
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For hospitalized patients on GLP-1s undergoing urgent or emergent diagnostic or therapeutic endoscopy, the panel:
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Care Customized to Patients
However, Drs. Gagneja and Ritter emphasized that “guidance” does not imply a one-size-fits-all approach. Dr. Ritter said he and his fellow anesthesiologists are “focusing on the ‘consider’ approach” in managing patients who did not stop their GLP-1s.
“If patients want to proceed and understand the potential aspiration risks, I go ahead. I had a patient on [semaglutide] for a year, who was asymptomatic, getting upper endoscopy and colonoscopy, and had taken the drug two days ago. He chose to proceed, and there was not a drop in his stomach,” Dr. Ritter said. “To me, that’s where the guidelines need to go: Individualize, check some evidence-based boxes, make sure the patient understands, and proceed if desired.”
—Caroline Helwick
Drs. Gagneja, Ritter and Schulman reported no relevant financial disclosures. Dr. Gagneja is a member of the Gastroenterology & Endoscopy News editorial board.
