Rowan BANDARANAIKE, Travis RUTLAND, Beth RUTLAND
Euroasian Journal of Hepato-Gastroenterology - 2026;16(1):112-118
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.
