GLP-1 Drugs May Not Need to Be Stopped Before Endoscopy If Proper Fasting Protocols Are Followed | Research

The takeaway

In 57 patients who continued GLP-1 drugs without interruption before endoscopic sleeve gastroplasty, zero cases of retained gastric solids, aspiration, regurgitation, or hypoxia occurred with a 24-hour liquid diet and 12-hour fast protocol.

Zero adverse events in 57 patients
Not a single case of retained gastric solids, aspiration, regurgitation, or oxygen desaturation occurred when patients continued their GLP-1 drugs with a 24-hour liquid diet and 12-hour fast — supporting the safety of continued GLP-1 RA use before upper endoscopy.

What the researchers found

Among 57 consecutive adults on GLP-1 RAs (45.6% semaglutide, 22.8% dulaglutide, 19.3% liraglutide, 12.3% tirzepatide) who underwent ESG without drug interruption:

- Zero instances of retained gastric solids

- Zero cases of pulmonary aspiration

- Zero cases of gastroesophageal regurgitation

- Zero episodes of hypoxia during intubation, endoscopy, or recovery

All patients followed a standardized preparation: liquid-only diet for ≥24 hours and nil per os for ≥12 hours before the procedure. The 100% safety record across multiple GLP-1 drugs and across three centers supports the adequacy of this fasting protocol.

Why it matters

Millions of patients on GLP-1 drugs need endoscopic and surgical procedures, and the question of whether to stop these medications has caused significant clinical confusion and patient anxiety. Stopping GLP-1 drugs can lead to blood sugar destabilization and weight regain. This study provides the first substantial case series evidence that continuing GLP-1 drugs may be safe with an appropriate extended fasting protocol, potentially simplifying procedural planning for millions of patients.

How the study worked

Retrospective case series reviewing all patients who underwent endoscopic sleeve gastroplasty while on uninterrupted GLP-1 RAs at three centers from August 2022 to February 2024. Patient records, procedure reports, and procedural videos were reviewed for retained gastric products and serious adverse events. All patients followed a standardized pre-procedure protocol (24-hour liquid diet, 12-hour complete fast).

What this study cannot tell us

This is a retrospective case series without a control group, making it impossible to compare outcomes with patients who did stop their GLP-1 drugs. The sample size (57 patients) is relatively small for detecting rare adverse events. All patients had native gastric anatomy — results may not apply to patients with prior gastric surgery. The extended fasting protocol (24-hour liquid diet) is more conservative than standard fasting and may not be practical for all procedure types. The case series was not designed to detect subclinical retained gastric contents.

How to read the evidence

This is a retrospective case series (Level IV evidence) without a control group. While the zero-event rate is reassuring, the small sample size limits the ability to detect rare complications. The multicenter design across three institutions adds credibility, but prospective randomized data would provide stronger evidence.

When this study was published

Published in 2024, this study addresses one of the most current debates in perioperative medicine and provides timely real-world data as GLP-1 drug use continues to expand rapidly.

The bigger picture

This study directly addresses one of the most pressing practical questions in perioperative GLP-1 drug management. The American Society of Anesthesiologists' 2023 recommendation to hold GLP-1 drugs before procedures created confusion, as it was not based on strong evidence. Multiple gastroenterology societies pushed back, calling for more data. This case series provides real-world evidence supporting a specific, practical protocol that may allow patients to continue their medications safely.

Questions still open

Would a shorter fasting protocol (e.g., 12-hour liquid diet instead of 24 hours) be equally safe for GLP-1 RA users undergoing endoscopy?
Is the zero-event rate in 57 patients sufficient to recommend widespread adoption, or are larger prospective studies needed?
Should pre-procedure gastric ultrasound be routinely performed to confirm stomach emptying even when following this extended fasting protocol?

Common questions

Do I need to stop semaglutide before an endoscopy?

This study suggests that if you follow a strict fasting protocol — liquids only for 24 hours and nothing by mouth for 12 hours before the procedure — you may not need to stop your GLP-1 medication. Zero complications occurred in 57 patients who continued their drugs. However, different guidelines exist, and you should discuss the best approach with both your gastroenterologist and prescribing doctor.

Why was there concern about GLP-1 drugs and endoscopy in the first place?

GLP-1 drugs slow how fast food leaves the stomach (delayed gastric emptying). During procedures requiring sedation, if food is still in the stomach, it can come back up and enter the lungs (aspiration) — a potentially dangerous complication. The concern was that even with standard fasting, patients on GLP-1 drugs might still have food in their stomachs. This study's extended fasting protocol appears to address that concern.

Read the original research

Safe Continuation of Glucagon-like Peptide 1 Receptor Agonists at Endoscopy: A Case Series of 57 Adults Undergoing Endoscopic Sleeve Gastroplasty.

Obesity surgery, 34(7), 2369-2374

View on PubMed ↗Publisher’s paper ↗

Citation

Maselli, Daniel B; Lee, Daniel; Bi, Danse; Jirapinyo, Pichamol; Thompson, Christopher C; Donnangelo, Lauren L; McGowan, Christopher E. (2024). Safe Continuation of Glucagon-like Peptide 1 Receptor Agonists at Endoscopy: A Case Series of 57 Adults Undergoing Endoscopic Sleeve Gastroplasty.. Obesity surgery, 34(7), 2369-2374. https://doi.org/10.1007/s11695-024-07278-2