In a new statement, five professional gastroenterology organizations caution that there are currently no data to support stopping glucagon-like peptide 1 (GLP-1) receptor agonists prior to elective endoscopy.
The medications, which include semaglutide (Ozempic, Wegovy), tirzepatide (Mounjaro), and liraglutide (Saxenda), among others, are used for the treatment of diabetes or for weight loss and may be associated with delayed gastric emptying.
"We really don't know what the risks are yet. With endoscopy, they could be significant, but perhaps they're not," Jonathan Leighton, MD, a gastroenterologist with Mayo Clinic Arizona and president-elect of the American College of Gastroenterology (ACG), told Medscape Medical News.
"There are a lot of factors that go into this, and we just want to proceed cautiously and carefully until we know more," he added.
The ACG, the American Gastroenterological Association (AGA), the American Association for the Study of Liver Diseases, the American Society for Gastrointestinal Endoscopy, and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition released the statement on August 11.
It was issued in response to recent guidance on the preoperative management of adults and children on GLP-1 receptor agonists put forth by the American Society of Anesthesiologists (ASA).
ASA Recommendations
The ASA Task Force on Preoperative Fasting reviewed the available literature on GLP-1 receptor agonists and associated gastrointestinal (GI) adverse effects, including the consequences of delayed gastric emptying.
The task force acknowledges that the evidence to provide guidance for preoperative management of these drugs to prevent regurgitation and pulmonary aspiration of gastric contents is "sparse, limited only to several case reports."
Nevertheless, given the concerns of GLP-1 receptor agonist–induced delayed gastric emptying and associated high risk for regurgitation and aspiration of gastric contents, the task force made these recommendations for elective procedures.
On the day(s) prior to the procedure:
- For patients on daily dosing, consider holding GLP-1 agonists on the day of the procedure/surgery. For patients on weekly dosing, consider holding GLP-1 agonists a week prior to the procedure/surgery.
- This suggestion is irrespective of the indication (type 2 diabetes or weight loss), dose, or the type of procedure/surgery.
- If GLP-1 agonists prescribed for diabetes are held for longer than the dosing schedule, consider consulting an endocrinologist for bridging the antidiabetic therapy to avoid hyperglycemia.
- If GI symptoms such as severe nausea/vomiting/retching, abdominal bloating, or abdominal pain are present, consider delaying the elective procedure and discuss the concerns of potential risk of regurgitation and pulmonary aspiration of gastric contents with the proceduralist/surgeon and the patient.
- If the patient has no GI symptoms and the GLP-1 agonists have been held as advised, proceed as usual.
- If the patient has no GI symptoms but the GLP-1 agonists were not held as advised, proceed with "full stomach" precautions or consider evaluating gastric volume by ultrasound, if possible and if proficient with the technique. If the stomach is empty, proceed as usual. If the stomach is full or if gastric ultrasound is inconclusive or not possible, consider delaying the procedure or treat the patient as "full stomach" and manage accordingly. Discuss the concerns of potential risk of regurgitation and pulmonary aspiration of gastric contents with the proceduralist/surgeon and the patient.
- There is no evidence to suggest the optimal duration of fasting for patients on GLP-1 agonists. Therefore, until we have adequate evidence, we suggest following the current ASA fasting guidelines.
For patients on GLP-1 receptor agonists who need urgent or emergent procedures, the ASA advises proceeding and treating the patient as "full stomach" and managing accordingly.
'Exercise Best Practices'
In their statement, the five gastroenterology organizations caution that "more data are needed to understand if and when these medications should be held prior to elective endoscopy.
"There is concern that this class of medication may be associated with safety issues regarding sedation and endoscopy. While there is anecdotal experience that increased gastroparesis risk may be dose dependent or related to whether it is being used for diabetes control versus weight loss, we also acknowledge that there is little or no data related to the relative risk of complications from aspiration," they state.
"As patient safety will always be paramount and in the absence of actionable data, we encourage our members to exercise best practices when performing endoscopy on these patients on GLP-1 receptor agonists," they add.
The five organizations also "encourage our anesthesiology, endocrinology, and industry partners to work collaboratively with our members to develop the necessary evidence to appropriately inform medication adjustments prior to elective endoscopy."
Awareness Advised
Patients taking GLP-1 receptor agonists for diabetes management "need to be cautious about withholding these medications because doing so can adversely impact blood glucose control," Octavia Pickett-Blakely, MD, a gastroenterologist with University of Pennsylvania in Philadelphia and spokesperson for the AGA, told Medscape Medical News. "In patients undergoing endoscopic procedures, poorly controlled blood glucose could raise the risk of complications."
In a commentary on Medscape, David Johnson, MD, professor of medicine and chief of gastroenterology in Eastern Virginia Medical School in Norfolk, Virginia, urges clinicians to learn about the topic and inform patients when prescribing GLP-1 receptor agonists.
"These are new and changing issues. In our world as gastroenterologists, we should be considering — very strongly — mitigating strategies to protect the patients on this wonderful class of therapy," he says. "Sometimes these drugs can have significant side effects that we need to at least be aware of. Nothing is perfect, but let us be better informed."
Leighton has financial relationships with Olympus and Pfizer. Pickett-Blakely has no relevant disclosures. Johnson is an advisor to ISOTHRIVE and Johnson & Johnson.
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