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Camilleri M. Definite benefits of GLP-1 receptor agonists: what is the risk of gastroparesis and lung aspiration? Gut 2024:gutjnl-2024-333036. [PMID: 39153846 DOI: 10.1136/gutjnl-2024-333036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Accepted: 08/02/2024] [Indexed: 08/19/2024]
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Facciorusso A, Ramai D, Dhar J, Samanta J, Chandan S, Gkolfakis P, Crinò SF, Maida M, Anderloni A, Boskoski I, Triantafyllou K, Dinis-Ribeiro M, Hassan C, Fuccio L, Arvanitakis M. Effects of Glucagon-Like Peptide-1 Receptor Agonists on Upper Gastrointestinal Endoscopy: A Meta-Analysis. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00717-1. [PMID: 39142543 DOI: 10.1016/j.cgh.2024.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 06/27/2024] [Accepted: 07/02/2024] [Indexed: 08/16/2024]
Abstract
BACKGROUND AND AIMS Limited evidence exists regarding the impact of glucagon-like peptide-1 receptor agonists (GLP-1RAs) on upper endoscopy. Therefore, a meta-analysis was conducted to comprehensively review the available evidence on this subject. METHODS A systematic bibliographic search was carried out until May 2024. Pooled estimates were analyzed using a random-effects model, with results presented as odds ratio (OR) and 95% confidence interval (CI). The primary outcome assessed was the rate of retained gastric content (RGC), while secondary outcomes included rates of aborted and repeated procedures, adverse event rate, and rates of aspiration. RESULTS This analysis included 13 studies involving a total of 84,065 patients. Patients receiving GLP-1RA therapy exhibited significantly higher rates of RGC (OR, 5.56; 95% CI, 3.35 to 9.23), a trend that was consistent among patients with diabetes (OR, 2.60; 95% CI, 2.23 to 3.02). Adjusted analysis, accounting for variables such as sex, age, body mass index, diabetes, and other therapies, confirmed the elevated rates of RGC in the GLP-1RA user group (adjusted OR, 4.20; 95% CI, 3.42 to 5.15). Furthermore, rates of aborted and repeated procedures were higher in the GLP-1RA user group (OR, 5.13; 95% CI, 3.01 to 8.75; and OR, 2.19; 95% CI, 1.43 to 3.35; respectively). However, no significant differences were found in AE and aspiration rates between the 2 groups (OR, 4.04; 95% CI, 0.63 to 26.03; and OR, 1.75; 95% CI, 0.64 to 4.77; respectively). CONCLUSION Use of GLP-1RAs is associated with increased retention of gastric contents and more frequent aborted procedures during upper endoscopy. However, the adverse event and aspiration rates do not seem different; therefore, adjusting fasting time instead of routinely withholding GLP-1RAs could be reasonable in these patients.
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Affiliation(s)
- Antonio Facciorusso
- Section of Gastroenterology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy; Clinical Effectiveness Research Group, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Daryl Ramai
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jahnvi Dhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Saurabh Chandan
- Center for Interventional Endoscopy, Advent Health, Orlando, Florida
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Konstantopoulio-Patision General Hospital of Nea Ionia, Athens, Greece
| | - Stefano Francesco Crinò
- Gastroenterology and Digestive Endoscopy Unit, Pancreas Institute, Department of Medicine, University Hospital of Verona, Verona, Italy
| | - Marcello Maida
- Department of Medicine and Surgery, School of Medicine and Surgery, University of Enna Kore, Enna, Italy
| | - Andrea Anderloni
- Endoscopy, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Ivo Boskoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, Attikon University General Hospital, National and Kapodastrian University of Athens, Athens, Greece
| | - Mario Dinis-Ribeiro
- Porto Comprehensive Cancer Center and RISE@CI-IPO, University of Porto, Porto, Portugal; Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Cesare Hassan
- Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Lorenzo Fuccio
- Department of Medical Sciences and Surgery, University of Bologna, Bologna, Italy
| | - Marianna Arvanitakis
- Department of Gastroenterology, Digestive Oncology and Hepatopancreatology, HUB Hôpital Erasme, Brussels, Belgium
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Hobai IA. Gastric Motility Assays May Not Capture the Entire Clinical Picture in Patients Using Glucagon-Like Peptide-1 Receptor Agonists. Am J Gastroenterol 2024:00000434-990000000-01286. [PMID: 39120044 DOI: 10.14309/ajg.0000000000002949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Accepted: 07/08/2024] [Indexed: 08/10/2024]
Affiliation(s)
- Ion A Hobai
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Al Sakka Amini R, Ismail ALS, Al-Aqrabawi M, Aleyadeh W, Mohammed A, Altork N, Abosheaishaa H, Elfert KA, Goble SR, Sawaf B, Chandan S. Risk of Aspiration Pneumonitis After Elective Esophagogastroduodenoscopy in Patients on Glucagon-Like Peptide-1 Receptor Agonists. Cureus 2024; 16:e66311. [PMID: 39238749 PMCID: PMC11376965 DOI: 10.7759/cureus.66311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2024] [Indexed: 09/07/2024] Open
Abstract
Background Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are gaining popularity in the management of diabetes mellitus and obesity. It has been suggested that this class of medications causes delayed gastric emptying which raised concerns about the potential for aspiration of gastric contents in patients undergoing sedation. This led to a statement by the American Society of Anesthesiologists about their preoperative use. Nevertheless, there is minimal evidence regarding the effects of GLP-1RAs on the risk of aspiration post-esophagogastroduodenoscopy (EGD). In this study, we sought to evaluate the incidence of aspiration and pneumonia in patients receiving GLP-1RAs who underwent EGD. Methodology We performed a retrospective cohort study in TriNetX, a global federated research network of electronic health records. The primary outcome was the development of aspiration post-EGD. Secondary outcomes were the development of aspiration pneumonia and requiring antibiotics post-EGD. One-to-one propensity score matching was performed for age, sex, diabetes mellitus, obesity, and other comorbidities between the cohorts. Results Our analysis showed a small but significant risk of aspiration pneumonitis in patients on GLP-1RAs undergoing elective EGD compared to non-GLP-1RA-receiving patients. However, there was no increased risk of the composite outcome of respiratory failure or intensive care unit (ICU) admission; however, this did not reach statistical significance. Conclusions GLP-1RA use was associated with an increased risk of aspiration in patients undergoing elective upper endoscopy. However, this did not translate to an increased risk of respiratory failure or ICU admission. Our findings highlight the importance of following an individualized approach to preoperative management that takes into consideration GLP-1RA indications and other aspiration risk factors, including advanced age, impaired gag reflex, and gastrointestinal symptoms such as nausea and abdominal distention.
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Affiliation(s)
| | | | | | | | - Abdul Mohammed
- Gastroenterology and Hepatology, AdventHealth Orlando, Orlando, USA
| | - Nadera Altork
- Medicine, Medstar Health/Georgetown-Washington Hospital Center, Washington, USA
| | - Hazem Abosheaishaa
- Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, New York, USA
- Internal Medicine/Gastroenterology, Cairo University, Cairo, EGY
| | - Khaled A Elfert
- Internal Medicine, St. Barnabas Hospital Health System, New York, USA
| | | | - Bisher Sawaf
- Internal Medicine, Hamad Medical Corporation, Doha, QAT
| | - Saurabh Chandan
- Gastroenterology and Hepatology, Creighton University, Omaha, USA
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Odah T, Vattikonda A, Stark M, Brahmbhatt B, Lukens FJ, Badurdeen D, Hashash JG, Farraye FA. Glucagon-like peptide-1 receptor agonists and capsule endoscopy in patients with diabetes: a matched cohort study. Gastrointest Endosc 2024:S0016-5107(24)03360-1. [PMID: 39094916 DOI: 10.1016/j.gie.2024.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Revised: 07/05/2024] [Accepted: 07/21/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND AND AIMS Video capsule endoscopy (VCE) is valuable for assessing conditions like GI bleeding, anemia, and inflammatory bowel disease. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are prescribed for diabetes and weight loss, with their pharmacologic effects including delayed gastric emptying. This study investigates the impact of GLP-1 RA use on VCE outcomes in patients with diabetes. METHODS This retrospective cohort study involves patients with diabetes undergoing VCE while on GLP-1 RAs matched in a 1:1 ratio with control subjects, who are not on GLP-1 RAs, based on demographics and diabetes-related factors. The primary outcome was gastric transit time in VCE studies, whereas secondary outcomes were incomplete small-bowel evaluation and small-bowel transit time. RESULTS In the GLP-1 RA cohort with 68 patients, 5 (7%) experienced failure to pass the video capsule through the stomach; all control subjects passed the video capsule successfully (P = .06). GLP-1 RA patients had a longer gastric transit time (99.3 ± 134.2 minutes) compared with control subjects (25.3 ± 31.6 minutes, P < .001). Multivariate analysis revealed GLP-1 RA use was associated with an increased gastric transit time by 74.5 minutes (95% confidence interval, 33.8-115.2; P < .001) compared with control subjects, after adjusting for relevant factors. Sixteen GLP-1 RA patients (23.5%) experienced incomplete passage of the video capsule through the small intestine, a significantly higher rate compared with 3 patients in the control group (4.4%, P < .01). CONCLUSIONS GLP-1 RA use is associated with a prolonged gastric transit time and a higher rate of incomplete small-bowel evaluation during VCE. Future studies may be crucial for evaluating strategies to mitigate these effects.
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Affiliation(s)
- Tarek Odah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Asrita Vattikonda
- Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Mark Stark
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Bhaumik Brahmbhatt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Frank J Lukens
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Dilhana Badurdeen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Jana G Hashash
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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Singh S, Suresh Kumar VC, Aswath G. Impact of glucagon-like peptide receptor agonists on endoscopy and its preoperative management: Guidelines, challenges, and future directions. World J Gastrointest Endosc 2024; 16:292-296. [PMID: 38946857 PMCID: PMC11212520 DOI: 10.4253/wjge.v16.i6.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/28/2024] [Accepted: 05/13/2024] [Indexed: 06/13/2024] Open
Abstract
Glucagon-like peptide receptor agonists (GLP-1RA) are used to treat type 2 diabetes mellitus and, more recently, have garnered attention for their effectiveness in promoting weight loss. They have been associated with several gastrointestinal adverse effects, including nausea and vomiting. These side effects are presumed to be due to increased residual gastric contents. Given the potential risk of aspiration and based on limited data, the American Society of Anesthesiologists updated the guidelines concerning the preoperative management of patients on GLP-1RA in 2023. They included the duration of mandated cessation of GLP-1RA before sedation and usage of "full stomach" precautions if these medications were not appropriately held before the procedure. This has led to additional challenges, such as extended waiting time, higher costs, and increased risk for patients. In this editorial, we review the current societal guidelines, clinical practice, and future directions regarding the usage of GLP-1RA in patients undergoing an endoscopic procedure.
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Affiliation(s)
- Sahib Singh
- Department of Internal Medicine, Sinai Hospital, Baltimore, MD 21215, United States
| | - Vishnu Charan Suresh Kumar
- Division of Gastroenterology and Hepatology, State University of New York Upstate Medical University, Syracuse, NY 13210, United States
| | - Ganesh Aswath
- Division of Gastroenterology and Hepatology, State University of New York Upstate Medical University, Syracuse, NY 13210, United States
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Barlowe TS, Anderson C, Sandler RS, Subramaniam D, Muratore A, Buse JB, Gouker LN, Majithia RT, Shaheen NJ, Stürmer T, Dougherty MK. Glucagon-Like Peptide-1 Receptor Agonists Do Not Increase Aspiration During Upper Endoscopy in Patients With Diabetes. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00453-1. [PMID: 38759826 DOI: 10.1016/j.cgh.2024.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 04/15/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND & AIMS Glucagon-like peptide-1-receptor agonists (GLP1-RAs) have been associated with greater retention of gastric contents, however, there is minimal controlled, population-based data evaluating the potential adverse effects of GLP1-RA in the periprocedural setting. We aimed to determine if there is increased risk of aspiration and aspiration-related complications after upper endoscopy in patients using GLP1-RAs. METHODS We used a nationwide commercial administrative claims database to conduct a retrospective cohort study of patients aged 18 to 64 with type 2 diabetes who underwent outpatient upper endoscopy from 2005 to 2021. We identified 6,806,046 unique upper endoscopy procedures. We compared claims for aspiration and associated pulmonary adverse events in the 14 days after upper endoscopy between users of GLP1-RAs, dipeptidyl peptidase 4 inhibitors (DPP4is), and chronic opioids. We adjusted for age, sex, Charlson Comorbidity score, underlying respiratory disease, and gastroparesis. RESULTS We found that pulmonary adverse events after upper endoscopy are rare, ranging from 6 to 25 events per 10,000 procedures. When comparing GLP1-RAs with DPP4i, crude relative risks of aspiration (0.67; 95% CI, 0.25-1.75), aspiration pneumonia (0.95; 95% CI, 0.40-2.29), pneumonia (1.07; 95% CI, 0.62-1.86), or respiratory failure (0.75; 95% CI, 0.38-1.48) were not higher in patients prescribed a GLP1-RA. When comparing GLP1-RAs with opioids, crude relative risks were 0.42 (95% CI, 0.15-1.16) for aspiration, 0.60 (95% CI, 0.24-1.52) for aspiration pneumonia, 0.30 (95% CI, 0.19-0.49) for pneumonia, and 0.24 (95% CI, 0.13-0.45) for respiratory failure. These results were consistent across several sensitivity analyses. CONCLUSIONS GLP1-RA use is not associated with an increased risk of pulmonary complications after upper endoscopy compared with DPP4i use in patients with type 2 diabetes.
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Affiliation(s)
- Trevor S Barlowe
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina.
| | - Chelsea Anderson
- Center for Gastrointestinal Biology and Disease, Chapel Hill, North Carolina
| | - Robert S Sandler
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, Chapel Hill, North Carolina
| | - Disha Subramaniam
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Alicia Muratore
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - John B Buse
- Division of Endocrinology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Lindsey N Gouker
- Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina
| | | | - Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, Chapel Hill, North Carolina
| | - Til Stürmer
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Michael K Dougherty
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina; UNC Rex Digestive Healthcare, Raleigh, North Carolina.
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Lupianez-Merly C, Dilmaghani S, Vosoughi K, Camilleri M. Review article: Pharmacologic management of obesity - updates on approved medications, indications and risks. Aliment Pharmacol Ther 2024; 59:475-491. [PMID: 38169126 DOI: 10.1111/apt.17856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Obesity has reached epidemic proportions, with >40% of the US population affected. Although traditionally managed by lifestyle modification, and less frequently by bariatric therapies, there are significant pharmacological advancements. AIMS To conduct a narrative review of the neurohormonal and physiological understanding of weight gain and obesity, and the development, clinical testing, indications, expected clinical outcomes, and associated risks of current FDA-approved and upcoming anti-obesity medications (AOMs). METHODS We conducted a comprehensive review in PubMed for articles on pathophysiology and complications of obesity, including terms 'neurohormonal', 'obesity', 'incretin', and 'weight loss'. Next, we searched for clinical trial data of all FDA-approved AOMs, including both the generic and trade names of orlistat, phentermine/topiramate, bupropion/naltrexone, liraglutide, and semaglutide. Additional searches were conducted for tirzepatide and retatrutide - medications expecting regulatory approval. Searches included combinations of terms related to mechanism of action, indications, side effects, risks, and future directions. RESULTS We reviewed the pathophysiology of obesity, including specific role of incretins and glucagon. Clinical data supporting the use of various FDA-approved medications for weight loss are presented, including placebo-controlled or, when available, head-to-head trials. Beneficial metabolic effects, including impact on liver disease, adverse effects and risks of medications are discussed, including altered gastrointestinal motility and risk for periprocedural aspiration. CONCLUSION AOMs have established efficacy and effectiveness for weight loss even beyond 52 weeks. Further pharmacological options, such as dual and triple incretins, are probable forthcoming additions to clinical practice for combating obesity and its metabolic consequences such as metabolic dysfunction-associated steatotic liver disease.
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Affiliation(s)
- Camille Lupianez-Merly
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Saam Dilmaghani
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kia Vosoughi
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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