Abstract
This cross-sectional study investigates the association between glucagon-like peptide-1 receptor agonists and food retention during esophagogastroduodenoscopy.
Introduction
Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are widely used for diabetes and weight management but are associated with risks for delayed gastric emptying and constipation.1 In June 2023, the American Society of Anesthesiologists raised concerns about the potential association between GLP-1RA use and risk of periprocedural aspiration.2 We investigated potential associations between GLP-1RAs use and risks of gastric food retention and periprocedural aspiration during esophagogastroduodenoscopies (EGDs) when EGD was combined with colonoscopy and in colonoscopy alone. We additionally evaluated risks of inadequate bowel preparation during colonoscopies.
Methods
We conducted a retrospective, single-center cross-sectional study of adults undergoing endoscopy between January 1, and June 28, 2023. The Cedars-Sinai Institutional Review Board approved the study, which followed the STROBE reporting guideline, and provided a waiver of informed consent. Individuals taking GLP-1RAs at the time of endoscopy were identified and matched 1:2 with individuals in a control group based on age, body mass index (BMI) subgroup, sex, and procedure. Exclusion criteria included use of prokinetics, surgically modified gastrointestinal anatomy, and exposure to GLP-1RAs within 90 days without actively taking them within 7 days of the procedure. Inadequate preparation was defined as aborting the procedure owing to stool burden or a Boston Bowel Preparation Scale score of less than 6 (total possible score, 9) or 0 (total possible score, 3) in any single bowel segment. Retained solid gastric content was identified based on endoscopist report (eMethods in Supplement 1).
Results
Among 70 individuals taking GLP-1RAs (mean [SD] age, 62.7 [12.2] years; 36 female) and 139 individuals in the control group (mean [SD] age, 62.7 [12.2] years; 36 female), the mean (SD) BMI was 34.4 (7.2) and 34.4 (7.2), respectively (Table). Among all individuals, 33% underwent EGD, 33% underwent colonoscopy, and 34% underwent both. In the GLP-1RA group, 46% received semaglutide, 30% received dulaglutide, 20% received tirzepatide, and 4% received liraglutide. Food retention occurred in 4 of 23 individuals (17.4%) in the GLP-1RA group undergoing EGD alone (1 moderate, 3 large) vs 0 of 46 individuals in the control group (odds ratio [OR], 21.5; 95% CI, 1.1-414.9; P = .01). No food retention was observed in combined EGD-colonoscopies (Figure).
Table. Characteristics and Outcomes of 209 Patients.
| Variable | GLP-1RA group (n = 70) | Control group (n = 139) | P value | ||
|---|---|---|---|---|---|
| Total with data, No. | No. (%) | Total with data, No | No. (%) | ||
| Characteristic | |||||
| Age, mean (SD), y | 70 | 62.7 (12.2) | 139 | 62.9 (12.3) | NR |
| EGD only | 23 | 61.5 (14.6) | 46 | 61.8 (14.8) | NR |
| Colonoscopy only | 23 | 61.6 (10.4) | 45 | 60.5 (10.2) | NR |
| Combination | 24 | 64.8 (11.5) | 48 | 66.0 (10.9) | NR |
| BMI, mean (SD) | 70 | 34.4 (7.2) | 139 | 33.2 (5.9) | NR |
| EGD only | 23 | 32.3 (4.8) | 46 | 31.4 (5.2) | NR |
| Colonoscopy only | 23 | 34.8 (7.3) | 45 | 33.6 (5.8) | NR |
| Combination | 24 | 36.0 (8.8) | 48 | 34.6 (6.2) | NR |
| Sex | |||||
| Female | 70 | 36 (51.4) | 139 | 72 (51.8) | NR |
| EGD only | 23 | 13 (56.5) | 46 | 26 (56.5) | NR |
| Colonoscopy only | 23 | 8 (34.8) | 45 | 16 (35.6) | NR |
| Combination | 24 | 15 (62.5) | 24 | 15 (62.5) | NR |
| Male | 70 | 34 (48.6) | 139 | 67 (48.2) | NR |
| EGD only | 23 | 10 (43.5) | 46 | 20 (43.5) | NR |
| Colonoscopy only | 23 | 15 (65.2) | 45 | 29 (64.4) | NR |
| Combination | 24 | 9 (37.5) | 24 | 9 (37.5) | NR |
| Race | |||||
| African American or Black | 70 | 10 (14.3) | 139 | 25 (18) | .56 |
| American Indian or Alaskan Native | 70 | 2 (2.9) | 139 | 2 (1.4) | .60 |
| Asian | 70 | 1 (1.4) | 139 | 6 (4.3) | .43 |
| Hawaiian or Pacific Islander | 70 | 0 (0) | 139 | 1 (0.7) | >.99 |
| White | 70 | 45 (64.3) | 139 | 93 (66.9) | .76 |
| Othera or not reported | 70 | 12 (17.1) | 139 | 12 (8.6) | .11 |
| Ethnicity | |||||
| Hispanic | 70 | 18 (25.7) | 139 | 30 (21.6) | .07 |
| Non-Hispanic | 70 | 50 (71.4) | 139 | 106 (76.3) | .45 |
| Not reported | 70 | 2 (2.9) | 139 | 3 (2.2) | >.99 |
| Obesity (BMI ≥30) | 70 | 50 (71.4) | 139 | 99 (71.2) | .98 |
| EGD only | 23 | 16 (69.6) | 46 | 32 (69.6) | >.99 |
| Colonoscopy only | 23 | 16 (69.6) | 45 | 31 (68.9) | .95 |
| Combination | 24 | 18 (75) | 48 | 36 (75) | >.99 |
| Diabetes | 70 | 58 (82.9) | 139 | 42 (30.2) | <.001 |
| EGD only | 23 | 19 (82.6) | 46 | 9 (19.6) | <.001 |
| Colonoscopy only | 23 | 16 (69.6) | 45 | 18 (40) | .02 |
| Combination | 24 | 23 (95.8) | 48 | 15 (31.3) | <.001 |
| Gastroparesis | 70 | 0 | 139 | 1 (0.7) | >.99 |
| EGD only | 23 | 0 | 46 | 0 | >.99 |
| Colonoscopy only | 23 | 0 | 45 | 1 (2.2) | >.99 |
| Combination | 24 | 0 | 48 | 0 | >.99 |
| Bowel preparation (used 4 L polyethylene glycol)b | 38 | 34 (89.5) | 73 | 59 (80.9) | .25 |
| Colonoscopy only | 19 | 17 (89.5) | 37 | 34 (91.9) | .66 |
| Combination | 19 | 17 (89.5) | 36 | 25 (69.4) | .11 |
| Outcomes | |||||
| Gastric food retention | 47 | 4 (8.5) | 94 | 0 | .01 |
| EGD only | 23 | 4 (17.4) | 46 | 0 | .006 |
| Combination | 24 | 0 | 48 | 0 | >.99 |
| Stool retention | 47 | 10 (21.3) | 93 | 6 (6.5) | .009 |
| Colonoscopy only | 23 | 2 (8.7) | 45 | 3 (6.7) | .76 |
| Combination | 24 | 8 (33.3) | 48 | 3 (6.3) | .003 |
| Aspiration | 70 | 0 | 139 | 0 | >.99 |
| EGD only | 23 | 0 | 46 | 0 | >.99 |
| Colonoscopy only | 23 | 0 | 45 | 0 | >.99 |
| Combination | 24 | 0 | 48 | 0 | >.99 |
Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); EGD, esophagogastroduodenoscopy; GLP-1RA, glucagon-like peptide-1 receptor agonist; NR, not reported (parameters on which groups were matched).
“Other” is an option patients can choose in the electronic medical record system from which data were obtained. No further data on the composition of this group are available.
For the GLP-1RA group, 47 patients had a colonoscopy, but data were available for only 38 individuals. For the control group, 93 patients had a colonoscopy, but data were available for 73 individuals.
Figure. Risk of Food Retention.
EGD indicates esophagogastroduodenoscopy; GLP-1RA, glucagon-like peptide-1 receptor agonist.
For individuals undergoing colonoscopy or combined EGD-colonoscopies, inadequate bowel preparation was more common in the GLP-1RA than control group (10 of 47 individuals [21.3%] vs 6 of 93 individuals [6.5%]; OR, 3.9; 95% CI, 1.3-11.6). No aspiration events, respiratory distress, or aspiration pneumonia visits occurred.
Discussion
This cross-sectional study found an association between use of GLP-1RAs and risks of retained gastric contents and inadequate bowel preparation during single endoscopic procedures. While others have explored this topic, this study is unique in examining these risks in EGD alone and when performed with colonoscopy.3 Importantly, we observed a low risk of food retention when EGD was combined with colonoscopy. This was suggested in a previous study,4 and our results confirm its consistency and reproducibility, supporting a potential utility in preprocedural risk stratification for patients receiving GLP-1RAs for chronic conditions. The protective association of concomitant colonoscopy is likely attributable to the 24-hour clear liquid diet and bowel preparation protocols typically required for colonoscopies.
The association between GLP-1RAs and risk of incomplete bowel preparation is not well described in the literature. Contrary to previous reports, our study identified a clear association between GLP-1RA use and unsatisfactory bowel preparation, which carries significant risks for missed lesions, patient dissatisfaction, and procedure cancellation, with wasted resources.5,6
Our results support the value of individualizing recommendations and inform the risk-benefit discussion for preprocedural counseling and same-day counseling when scheduled procedures may be canceled because GLP-1RAs are not held. Importantly, our findings suggest that patients who adhere to colonoscopy preparation guidance may be at a low risk of retained gastric contents and aspiration. However, future studies are necessary to confirm and validate the role of this finding in preoperative risk assessment. Study limitations include a retrospective nature; an inability to match for diabetes or account for other factors, such as glycemia, or examine differential associations of individual GLP-1RAs and doses; and a sample size that precluded analysis of rare events, such as aspiration.
eMethods.
Data Sharing Statement
References
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Associated Data
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Supplementary Materials
eMethods.
Data Sharing Statement
