Abstract
Aims and background
Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are used by over 15 million US adults, yet conflicting guidance from the American Gastroenterological Association (AGA) and American Society of Anesthesiologists (ASA) has created clinical uncertainty regarding periprocedural management, contributing to procedure cancellation rates approaching 30%. This narrative review synthesizes the published evidence on residual gastric contents (RGC), pulmonary aspiration risk, and periprocedural management strategies for patients taking GLP-1 RAs undergoing upper gastrointestinal (GI) endoscopy.
Methods
PubMed, MEDLINE, and Google Scholar were searched through January 2026 for randomized controlled trials (RCTs), published meta-analyses, observational cohort studies, and international society guidelines addressing GLP-1 RA use and upper GI endoscopy outcomes.
Results
Evidence encompassing over 2,60,000 patients demonstrates that GLP-1 RA use is associated with increased RGC [odds ratio (OR): 4.54–5.57] and higher procedure cancellation rates (OR: 4.54–4.90). Meta-analyses have not consistently identified significant increases in pulmonary aspiration (OR: 0.96–2.29). The OCULUS randomized trial found that holding one dose reduced clinically significant RGC from 25.0 to 3.1% for isolated esophagogastroduodenoscopy (EGD) (p = 0.003). Combined procedures showed minimal RGC regardless of medication continuation.
Conclusion
An individualized, procedure-specific approach emphasizing 24-hour clear liquid dietary modification rather than routine medication discontinuation is supported by the available evidence. Guideline harmonization and standardized point-of-care gastric ultrasound (POCUS) protocols are urgent priorities.
Clinical significance
Glucagon-like peptide-1 receptor agonist use significantly increases RGCs before upper endoscopy, but dietary modification with a 24-hour clear liquid diet—rather than routine medication discontinuation—appears to be the key determinant of gastric emptying. Clinicians should adopt an individualized, procedure-specific approach to reduce unnecessary procedure cancellations while maintaining patient safety.
Keywords: Endoscopy gastrointestinal, Gastric emptying, Glucagon-like peptide 1, Glucagon-like peptide-1 receptor agonists, Narrative review, Perioperative care, Respiratory aspiration, Semaglutide
Introduction
Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have emerged as one of the most rapidly expanding medication classes in modern medicine. As of 2024, approximately 6% of US adults—over 15 million individuals—report current use of these agents.1 Food and Drug Administration (FDA)-approved indications now span type 2 diabetes mellitus, obesity, cardiovascular risk reduction, chronic kidney disease, and metabolic dysfunction-associated steatohepatitis.2–4
The mechanism of action of GLP-1 RAs includes delayed gastric emptying, which has raised concerns regarding residual gastric contents (RGC) and potential aspiration risk during sedated procedures.5 This has created a clinical dilemma for gastroenterologists and anesthesiologists managing the growing population of patients on these medications who require upper gastrointestinal (GI) endoscopy.
Conflicting guidance from major professional societies has compounded this uncertainty. The American Society of Anesthesiologists (ASA) recommended holding GLP-1 RAs for varying durations based on dosing frequency, while the American Gastroenterological Association (AGA) suggested that routine discontinuation may be unnecessary.6,7 This discordance has contributed to procedure cancellation rates approaching 30% in affected patients, exacerbating post-pandemic endoscopy backlogs and potentially delaying colorectal cancer diagnoses.8
The clinical relevance of this issue extends beyond routine screening. Glucagon-like peptide-1 receptor agonists are also being investigated for potential anti-inflammatory effects in inflammatory bowel disease, further expanding the population requiring periprocedural guidance.9 As GLP-1 RA use expands across gastroenterological indications, the need for evidence-based periprocedural guidance becomes increasingly urgent.
Despite widespread clinical use, no consensus exists on optimal periprocedural management. High-quality randomized evidence has been lacking until the recent publication of the OCULUS trial in 2026.10 The purpose of this narrative review is to synthesize and interpret the current published literature on RGC, pulmonary aspiration risk, and periprocedural management strategies for patients taking GLP-1 RAs undergoing upper GI endoscopy, with the goal of providing clinicians with practical, evidence-based recommendations.
Methods
This is a narrative review of the published literature on GLP-1 RAs and upper GI endoscopy outcomes. No systematic review, original meta-analysis, or independent data analysis was performed. No Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) methodology was employed. The rationale for a narrative rather than systematic approach is that the heterogeneity of study designs, guideline documents, and outcome definitions across the included literature makes formal pooling less informative than narrative synthesis. This study did not involve human subjects or patient data. Institutional review board approval was not required.
PubMed, MEDLINE, and Google Scholar were searched through January 2026 using terms including “GLP-1 receptor agonist,” “semaglutide,” “tirzepatide,” “liraglutide,” “upper endoscopy,” “esophagogastroduodenoscopy,” “residual gastric contents,” “gastric emptying,” and “aspiration.” Reference lists of key articles were reviewed for additional relevant publications. No formal inclusion/exclusion criteria were applied; rather, studies were selected based on relevance, recency, and clinical applicability.
Randomized controlled trials (RCTs), published systematic reviews and meta-analyses conducted by other investigators, large observational cohort studies, and clinical practice guidelines from major professional societies were reviewed. All statistical data reported in this review [odds ratios (ORs), confidence intervals (CIs), p values] are derived directly from these published sources and were not independently calculated or verified by the authors.
International society guidelines reviewed included the AGA Rapid Clinical Practice Update (2024), ASA Consensus-Based Guidance (2023, updated 2024), American Diabetes Association (ADA) Standards of Care (2026), the joint Australian Diabetes Society/Australian and New Zealand College of Anaesthetists/Gastroenterological Society of Australia/National Australian Committee of Obesity Surgery (ADS/ANZCA/GESA/NACOS) Clinical Practice Recommendations (2025), and the Italian Society of Gastroenterology (SIGE) Position Paper (2026).6,7,11–13
Primary outcomes discussed include RGC, pulmonary aspiration, and procedure cancellation. Secondary topics include periprocedural mitigation strategies, glycemic considerations following medication discontinuation, and point-of-care assessment modalities.
Results
Residual Gastric Contents
Published evidence from observational studies and the OCULUS randomized trial, encompassing over 2,60,000 patients across up to 23 studies in multiple meta-analyses, consistently demonstrates that GLP-1 RA use is associated with significantly increased RGC.10,14–16
Facciorusso et al. conducted a meta-analysis of 13 studies and reported that GLP-1 RA use was associated with significantly higher odds of RGC (OR: 5.56; 95% CI 3.35–9.23; p < 0.001).16 Baig et al. reported an OR of 4.54 (95% CI: 3.30–6.24) for RGC across 23 studies encompassing 2,62,018 patients.15 Abdulraheem et al., in a more recent meta-analysis of 20 studies, reported an OR of 5.57 (95% CI: 4.07–7.62).14 Table 1 summarizes the published meta-analytic findings.
Table 1.
Summary of published meta-analyses on GLP-1 RA use and endoscopy outcomes
| Study | Studies, No. | Patients, No. | RGC, OR (95% CI) | Aspiration, OR (95% CI) | Cancellation, OR (95% CI) |
|---|---|---|---|---|---|
| Facciorusso et al., 202516 | 13 | NR | 5.56 (3.35–9.23)a | 1.75 (0.64–4.77) | NR |
| Baig et al., 202515 | 23 | 262,018 | 4.54 (3.30–6.24)a | 0.96 (0.53–1.75) | 4.54 (2.94–7.01)a |
| Abdulraheem et al., 202514 | 20 | NR | 5.57 (4.07–7.62)a | 1.23 (0.71–2.13) | 4.90 (2.94–8.18)a |
| Tan et al., 202517 | NR | NR | NR | 2.29 (1.36–3.87)a | NR |
CI, confidence interval; GLP-1 RA, glucagon-like peptide-1 receptor agonist; NR, not reported; OR, odds ratio; RGC, residual gastric contents. aStatistically significant (p < 0.05).
The OCULUS trial, published in 2026, represents the first RCT addressing this question.10 This multicenter, open-label trial randomized 154 patients across four US academic centers who were taking GLP-1 RAs (semaglutide, tirzepatide, liraglutide, or dulaglutide) or dual GLP-1/glucose-dependent insulinotropic polypeptide (GIP) agonists to either hold one dose or continue their medication before upper endoscopy. The primary outcome was clinically significant RGC, defined as solid food residue requiring procedure modification, termination, or repeat intervention.
For isolated esophagogastroduodenoscopy (EGD), the hold group demonstrated a clinically meaningful reduction in RGC from 25.0 to 3.1% (p = 0.003), with a number needed to treat (NNT) of approximately 5. Notably, the “hold one dose” protocol was operationalized as one dosing interval—1 week for weekly agents (semaglutide, tirzepatide, dulaglutide) and 1 day for daily agents (liraglutide)—rather than a fixed calendar duration. This distinction is critical for clinical implementation.
For combined EGD/colonoscopy, no patients in either group experienced clinically significant RGC, reinforcing the protective effect of the standard 24-hour clear liquid bowel preparation. No aspiration events occurred in either arm, though the trial was not powered to detect differences in this rare outcome.
Procedure Cancellations
Glucagon-like peptide-1 receptor agonist use is associated with significantly higher procedure cancellation rates based on published meta-analyses. Baig et al. reported an OR of 4.54 (95% CI: 2.94–7.01) for procedure cancellation.15 Abdulraheem et al. found similar results with an OR of 4.90 (95% CI: 2.94–8.18).14 Cancellations occur primarily due to visualization impairment from solid food residue or concern for aspiration risk, representing a significant burden on healthcare resources and patient care.
Pulmonary Aspiration
The relationship between GLP-1 RA use and pulmonary aspiration remains uncertain, with conflicting results across published meta-analyses. Baig et al. reported an OR of 0.96 (95% CI: 0.53–1.75) for aspiration, not reaching statistical significance.15 Facciorusso et al. found an OR of 1.75 (95% CI: 0.64–4.77), also not statistically significant.16 Abdulraheem et al. reported an OR of 1.23 (95% CI: 0.71–2.13).14
However, Tan et al., in a 2025 meta-analysis, reported a statistically significant association between GLP-1 RA use and pulmonary aspiration (OR: 2.29; 95% CI: 1.36–3.87).17 The discrepancy between Tan et al. and the other three meta-analyses warrants careful examination.17 Several methodological differences may explain the divergent findings. First, study inclusion criteria varied: Tan et al. included studies with broader aspiration definitions encompassing both clinical aspiration events and radiographic evidence of aspiration, whereas other meta-analyses applied more restrictive definitions limited to clinically apparent aspiration pneumonia or aspiration pneumonitis.17 Second, the handling of zero-event studies differed across analyses. For rare outcomes such as aspiration, the choice of continuity correction (typically adding 0.5 to zero cells) can substantially influence pooled ORs, and different statistical approaches to these sparse data may account for the observed variation.
Combined Upper and Lower Endoscopy
A critical finding reported across multiple studies is that patients undergoing combined EGD and colonoscopy, who follow a 24-hour clear liquid diet as part of standard bowel preparation, have minimal to no clinically significant RGC regardless of GLP-1 RA continuation.10,14–16 The OCULUS trial found that no patients undergoing combined procedures experienced clinically significant RGC in either the hold or continue groups.10 Published meta-analyses report ORs of 0.27–0.28 for RGC in combined procedures.14,15 This suggests that dietary modification rather than medication discontinuation may be the key determinant of gastric emptying.
Comparison among GLP-1 RA Agents
A published network meta-analysis comparing individual GLP-1 RA agents—semaglutide (Novo Nordisk, Bagsværd, Denmark), tirzepatide (Eli Lilly, Indianapolis, Indiana, USA), liraglutide (Novo Nordisk), dulaglutide (Eli Lilly), and exenatide (AstraZeneca, Cambridge, United Kingdom)—found no significant differences in RGC risk among agents (Chi-square: 0.966, p = 0.96).14 This suggests a class effect rather than agent-specific risk, simplifying clinical decision-making. Table 2 compares individual GLP-1 RA agents.
Table 2.
Comparison of individual GLP-1 RA agents
| Agent | Manufacturer | Dosing frequency | Mechanism | RGC risk |
|---|---|---|---|---|
| Semaglutide (Ozempic/Wegovy) | Novo Nordisk, Bagsværd, Denmark | Weekly SC | GLP-1 RA | Class effecta |
| Tirzepatide (Mounjaro/Zepbound) | Eli Lilly, Indianapolis, IN, USA | Weekly SC | Dual GLP-1/GIP RA | Class effecta |
| Liraglutide (Victoza/Saxenda) | Novo Nordisk, Bagsværd, Denmark | Daily SC | GLP-1 RA | Class effecta |
| Dulaglutide (Trulicity) | Eli Lilly, Indianapolis, IN, USA | Weekly SC | GLP-1 RA | Class effecta |
| Exenatide (Byetta/Bydureon) | AstraZeneca, Cambridge, UK | Daily or weekly SC | GLP-1 RA | Class effecta |
| Oral semaglutide (Rybelsus) | Novo Nordisk, Bagsværd, Denmark | Daily oral | GLP-1 RA | Class effecta |
GIP, glucose-dependent insulinotropic polypeptide; GLP-1 RA, glucagon-like peptide-1 receptor agonist; RGC, residual gastric contents; SC, subcutaneous. aNetwork meta-analysis found no significant differences in RGC risk among agents (Chi-square: 0.966, p = 0.96)14
Discussion
Interpretation of RGCs and Aspiration Risk
The consistent finding of increased RGC across all published meta-analyses (ORs: 4.54–5.57) is biologically plausible given the known mechanism of GLP-1 RA–mediated delayed gastric emptying and is consistent across different study designs, populations, and geographic settings.14–16 However, the clinical significance of increased RGC depends on whether it translates into meaningful aspiration risk.
The absolute risk context is essential for clinical interpretation. Even accepting the highest reported OR of 2.29 from Tan et al., the baseline aspiration rate during elective upper endoscopy is approximately 0.01–0.02%.17 An OR of 2.29 would translate to an absolute risk of approximately 0.02–0.05%, yielding a number needed to harm (NNH) exceeding 2,000. This absolute risk framing suggests that even if a true association exists, the clinical magnitude is small relative to the harms of routine procedure cancellation, including delayed cancer diagnoses and patient anxiety.
None of the meta-analyses were able to distinguish aspiration occurring during endoscopy from post-procedural aspiration events, and none stratified by sedation type (moderate sedation vs general anesthesia with endotracheal intubation), which represents a significant confounding variable. Future studies should adopt standardized aspiration definitions and report sedation-stratified outcomes.
The OCULUS Trial in Context
Several limitations of the OCULUS trial should be noted.10 The sample size of 154 patients provides adequate power for the primary RGC endpoint but is insufficient to assess aspiration risk, which occurs at a baseline rate of approximately 0.01–0.02% during elective endoscopy. The open-label design introduces potential assessment bias, though the objective nature of the primary endpoint (presence of solid food residue) mitigates this concern. Enrollment at academic centers with experienced endoscopists may limit generalizability to community practice settings. Additionally, the trial did not assess endoscopist-reported visualization quality scores or procedure duration, which would have provided additional clinically relevant data. Despite these limitations, the OCULUS trial represents a significant advance from the exclusively observational evidence base that previously informed clinical practice.
The finding that combined procedures with 24-hour clear liquid diets have minimal RGC regardless of medication continuation suggests that dietary modification may be the more important intervention. This has significant implications for clinical practice, as it suggests a simpler, more patient-centered approach may be equally effective.
Duration of Discontinuation and Glycemic Consequences
Prolonged discontinuation of GLP-1 RAs does not reliably normalize gastric emptying based on available evidence. A systematic review and meta-analysis found that GLP-1 RA type, mechanism of action, and treatment duration did not significantly impact gastric emptying metrics (p < 0.05), suggesting that prolonged discontinuation does not reliably normalize gastric emptying.18 Furthermore, extended discontinuation risks glycemic destabilization in patients with diabetes, potentially causing more harm than the theoretical aspiration risk.11,12
The glycemic consequences of prolonged GLP-1 RA discontinuation are clinically significant. Weekly semaglutide has a half-life of approximately 7 days, requiring 4–5 weeks to return to steady-state concentrations after interruption. During this period, patients with type 2 diabetes may experience clinically meaningful hyperglycemia, with case series reporting blood glucose excursions exceeding 300 mg/dL following perioperative GLP-1 RA discontinuation. The ADA Standards of Care emphasize that the risk of hyperglycemic complications—including diabetic ketoacidosis in susceptible individuals—may exceed the theoretical aspiration risk, particularly given the low absolute aspiration rates discussed above.11 For patients using GLP-1 RAs for weight management, discontinuation may trigger rebound appetite, weight regain, and GI symptoms. These metabolic consequences further support the recommendation to limit discontinuation to a single dose interval rather than prolonged withholding.
Point-of-care Gastric Ultrasound (POCUS)
Point-of-care gastric ultrasound has emerged as a promising tool for individualized risk assessment, with validation studies demonstrating sensitivity of 1.0 (95% CI: 0.925–1.0) and specificity of 0.975 (95% CI: 0.95–1.0) for detecting gastric contents.19 The gastric ultrasound technique involves measurement of the antral cross-sectional area in the right lateral decubitus position using a low-frequency curvilinear transducer. The Perlas qualitative grading system classifies findings as grade 0 (empty antrum), grade I (clear fluid only), or grade II (solid content or thick fluid). Quantitative assessment using the antral cross-sectional area can estimate gastric volume, with volumes exceeding 1.5 mL/kg generally considered elevated.
In the context of GLP-1 RA use, POCUS could serve as a triage tool: Patients with grade 0 or grade I findings could proceed with standard sedation, while those with grade II findings could be managed with procedure delay, enhanced fasting, or airway protection strategies. The ADS/ANZCA/GESA/NACOS guidelines specifically endorse this approach.12
However, several barriers to implementation exist. No validated POCUS protocol specific to GLP-1 RA populations has been established. Training requirements remain undefined—it is unclear whether gastroenterologists, anesthesiologists, or trained nurses should perform the assessment. Equipment availability in outpatient endoscopy suites varies widely. Most importantly, no randomized trial has demonstrated that POCUS-guided management improves clinical outcomes such as aspiration rates or procedure completion. These gaps represent important targets for future research.
Guideline Recommendations
Current guidelines reflect evolving evidence but remain discordant (Table 3). The ASA 2023 guidance recommended holding daily GLP-1 RAs on the day of procedure and weekly agents for 1 week prior.7 The 2024 update acknowledged emerging evidence but maintained conservative recommendations pending additional data.
Table 3.
Comparison of International Society Guideline Recommendations for Periprocedural Management of GLP-1 RAs
| Organization/year | Medication recommendation | Dietary recommendation | Risk assessment | Key considerations |
|---|---|---|---|---|
| ASA 2023/2024 | Hold daily agents day of procedure; hold weekly agents 1-week prior | Standard NPO guidelines | Not specified | Conservative approach; updated 2024 but maintained recommendations |
| AGA 2024 | Continuation reasonable if asymptomatic; hold if GI symptoms present | 24 hr clear liquid diet for isolated EGD | Symptom-based assessment | Emphasizes shared decision-making; supports continuation for combined procedures |
| ADA 2026 | Individualized assessment; avoid prolonged discontinuation | Not specifically addressed | Balance procedural vs metabolic risk | Cautions against glycemic destabilization from extended interruption |
| ADS/ANZCA/GESA/NACOS 2025 | Dietary modification preferred over routine discontinuation | 24 hr clear liquid diet | POCUS recommended for risk stratification | Most comprehensive guidance; multidisciplinary consensus |
| SIGE 2026 | Routine discontinuation not recommended | Not specifically addressed | Individualized assessment | Aligns with AGA; first European society paper |
ADA, American Diabetes Association; ADS, Australian Diabetes Society; AGA, American Gastroenterological Association; ANZCA, Australian and New Zealand College of Anaesthetists; ASA, American Society of Anesthesiologists; EGD, esophagogastroduodenoscopy; GESA, Gastroenterological Society of Australia; GI, gastrointestinal; GLP-1 RA, glucagon-like peptide-1 receptor agonist; NACOS, National Australian Committee of Obesity Surgery; NPO, nil per os; POCUS, point-of-care ultrasound; SIGE, Italian Society of Gastroenterology
The AGA 2024 Rapid Clinical Practice Update suggested that for patients without GI symptoms (nausea, vomiting, dyspepsia, and abdominal distension), proceeding without medication discontinuation may be reasonable, particularly for combined procedures.6
The ADA 2026 Standards of Care recommend individualized assessment, noting that prolonged discontinuation may cause glycemic harm and that the decision should balance procedural risk against metabolic consequences.11
The ADS/ANZCA/GESA/NACOS 2025 joint recommendations represent the most comprehensive guidance to date, emphasizing dietary modification (24-hour clear liquid diet) over routine medication discontinuation and supporting POCUS for risk stratification.12
The SIGE 2026 Position Paper concluded that routine discontinuation of GLP-1 RAs before upper GI endoscopy is not recommended, aligning with the AGA position and further supporting a dietary modification-centered approach.13
The global relevance of this issue extends beyond North American practice. Glucagon-like peptide-1 receptor agonists prescribing is expanding rapidly across Europe, the Middle East, and the Asia-Pacific region, with semaglutide now approved in over 100 countries. Periprocedural management protocols may require adaptation based on regional factors, including anesthesia staffing models (anesthesiologist-directed vs endoscopist-directed sedation), POCUS equipment availability, and local prescribing patterns. The convergence of the Australian, Italian, and American guidelines toward dietary modification over routine discontinuation suggests an emerging international consensus, though region-specific validation studies would strengthen the evidence base.20
Limitations of the Study
Several limitations of this review should be acknowledged. As a narrative rather than a systematic review, formal systematic methodology, PRISMA reporting, or independent data analysis was not employed. Literature selection was based on author judgment rather than predefined inclusion and exclusion criteria, introducing potential selection bias. Publication bias or incomplete literature capture remains possible, as the search was limited to PubMed, MEDLINE, and Google Scholar without the inclusion of gray literature or unpublished data.
The observational nature of most primary studies included in this review introduces potential confounding, including differences in patient populations, GLP-1 RA dosing, fasting protocols, and sedation practices across studies. Definitions of RGC varied across studies—ranging from any visible gastric contents to solid food residue requiring procedure modification—limiting direct comparisons and potentially inflating or deflating reported effect sizes.
Pulmonary aspiration is a rare event, and even pooled analyses across multiple meta-analyses may be underpowered to detect clinically meaningful differences. The inability to stratify aspiration events by sedation type (moderate sedation vs general anesthesia with endotracheal intubation) or by timing (intraprocedural vs post-procedural) represents a significant limitation of the existing evidence base.
The OCULUS trial, while providing important randomized evidence, was conducted at four experienced US academic centers with a sample size of 154 patients and may not generalize to all practice settings, particularly community endoscopy centers with different sedation practices and patient populations.10 Additionally, the open-label design of the OCULUS trial introduces potential assessment bias, though the objective nature of the primary endpoint mitigates this concern.
Finally, the rapidly evolving nature of this field means that additional evidence published after the search date of January 2026 may not be captured in this review. The recommendations presented should be interpreted in the context of these limitations and updated as new evidence emerges.
Conclusion
Glucagon-like peptide-1 receptor agonist use increases RGC, with published meta-analyses consistently reporting ORs in the 4.5–5.6 range.14–16 The relationship between increased RGC and pulmonary aspiration remains uncertain, with conflicting meta-analytic findings.14–17 The OCULUS trial provides the first randomized evidence that holding one dose effectively reduces RGC for isolated EGD, while combined procedures with 24-hour clear liquid diets have minimal RGC regardless of medication continuation.10
An individualized, procedure-specific approach is supported, with 24-hour clear liquid dietary modification representing the primary periprocedural strategy rather than routine medication discontinuation. For isolated upper endoscopy, holding one dose provides additional risk reduction. Prolonged medication discontinuation is not supported by evidence and may cause harm through glycemic destabilization.11,12
Based on the evidence reviewed, the following practical recommendations are proposed (Table 4). For combined EGD/colonoscopy, GLP-1 RA therapy should be continued; standard 24-hour clear liquid bowel preparation is sufficient. For isolated EGD, holding one dose and implementing a 24-hour clear liquid diet is recommended. Prolonged discontinuation (>1 dose) should be avoided due to glycemic risks without additional benefit. Point-of-care gastric ultrasound should be considered for symptomatic patients (nausea, vomiting, and bloating). Procedures should not be routinely canceled solely due to GLP-1 RA use.
Table 4.
Evidence-based clinical recommendations for periprocedural GLP-1 RA management
| Clinical scenario | Recommendation | Supporting evidence |
|---|---|---|
| Combined EGD/colonoscopy | Continue GLP-1 RA; standard 24 hr clear liquid bowel preparation is sufficient | OCULUS RCT: 0% clinically significant RGC in both groups; meta-analyses: OR: 0.27–0.2810,14,15 |
| Isolated EGD | Hold one dose; implement a 24 hr clear liquid diet | OCULUS RCT: RGC reduced from 25.0 to 3.1% (p = 0.003)10 |
| Symptomatic patients (nausea, vomiting, bloating) | Consider POCUS for risk stratification; hold one dose; 24 hr clear liquid diet | ADS/ANZCA/GESA/NACOS guidelines; POCUS sensitivity 1.0, specificity 0.97512,19 |
| Duration of discontinuation | Avoid prolonged discontinuation (>1 dose) | Gastric emptying not reliably normalized by prolonged hold; glycemic destabilization risk11,12,18 |
| Procedure cancellation | Do not routinely cancel solely due to GLP-1 RA use | Cancellation OR: 4.54–4.90 represents overreaction to uncertain aspiration risk14,15 |
ADS, Australian Diabetes Society; ANZCA, Australian and New Zealand College of Anaesthetists; EGD, esophagogastroduodenoscopy; GESA, Gastroenterological Society of Australia; GLP-1 RA, glucagon-like peptide-1 receptor agonist; NACOS, National Australian Committee of Obesity Surgery; OR, odds ratio; POCUS, point-of-care ultrasound; RCT, randomized controlled trial; RGC, residual gastric contents
Several urgent priorities emerge from this review. First, harmonization of AGA and ASA guidance is needed to reduce clinical confusion and unnecessary procedure cancellations.6,7 Second, standardized POCUS protocols and training curricula should be developed to enable widespread implementation of individualized risk assessment.19 Third, larger randomized trials powered for aspiration outcomes would provide definitive evidence, though the rarity of this event makes such studies challenging. Fourth, studies examining the optimal duration of clear liquid diet and the role of prokinetic agents warrant investigation.
Clinical Significance
Glucagon-like peptide-1 receptor agonist use is associated with a 4.5- to 5.6-fold increase in RGCs before upper endoscopy, though the impact on pulmonary aspiration remains uncertain, with absolute risk increases likely below 0.05%. A 24-hour clear liquid diet—rather than routine medication discontinuation—appears to be the primary determinant of gastric emptying, as demonstrated by the absence of clinically significant RGCs in combined EGD/colonoscopy procedures regardless of GLP-1 RA continuation. Clinicians should adopt an individualized, procedure-specific approach: Continuing GLP-1 RAs for combined procedures with standard bowel preparation, and holding one dose for isolated EGD, to reduce unnecessary procedure cancellation rates approaching 30% while maintaining patient safety.
Declarations
Ethical Approval
Nil. This narrative review did not involve human subjects, patient data, or animal experimentation. Institutional review board approval was not required.
Data Availability Declaration
No original data were generated or analyzed in this narrative review. All data discussed herein are derived from previously published studies, which are cited in the References section. No datasets were created or curated during the preparation of this manuscript.
Acknowledgment
None.
Authors’ Contributions
Rowan Bandaranaike contributed to the conception and design of the review, literature search and selection, drafting of the original manuscript, and critical revision for important intellectual content. Beth Rutland contributed to the literature search, data extraction from published sources, drafting of the manuscript, and preparation of tables and figures. Travis Rutland contributed to the critical revision of the manuscript for important intellectual content and provided expert clinical input on periprocedural management recommendations. All authors reviewed and approved the final version of the manuscript and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Artificial Intelligence (AI) disclosure
The authors declare that no AI is used within the study performed.
Orcid
Rowan Bandaranaike https://orcid.org/0009-0008-1082-3584
Footnotes
Source of support: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflict of interest: None
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Associated Data
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Data Availability Statement
No original data were generated or analyzed in this narrative review. All data discussed herein are derived from previously published studies, which are cited in the References section. No datasets were created or curated during the preparation of this manuscript.