Glucagon-like peptide-1 receptor agonists before upper gastrointestinal endoscopy and risk of pulmonary aspiration or discontinuation of procedure: cohort study
Open accessAbstract
Objective: To assess whether use of glucagon-like peptide-1 (GLP-1) receptor agonists before upper gastrointestinal endoscopy is associated with increased risk of pulmonary aspiration or discontinuation of the procedure compared with sodium-glucose cotransporter-2 (SGLT-2) inhibitors. Design: Cohort study. Setting: Two deidentified US commercial healthcare databases. Participants: 43 365 adults (≥18 years) with type 2 diabetes who used a GLP-1 receptor agonist or SGLT-2 inhibitor within 30 days before upper gastrointestinal endoscopy. Main outcome measures: The primary outcome was pulmonary aspiration on the day of or the day after endoscopy, defined using diagnostic codes. The secondary outcome was discontinuation of endoscopy. Risk ratios and corresponding 95% confidence intervals (CIs) were estimated after fine stratification weighting based on propensity score. Results: After weighting, 24 817 adults used a GLP-1 receptor agonist (mean age 59.9 years; 63.6% female) and 18 537 used an SGLT-2 inhibitor (59.8 years; 63.7% female). Among users of GLP-1 receptor agonists and SGLT-2 inhibitors, the weighted risk per 1000 people was, respectively, 4.15 and 4.26 for pulmonary aspiration and 9.79 and 4.91 for discontinuation of endoscopy. Compared with SGLT-2 inhibitor use, GLP-1 receptor agonist use was not associated with an increased risk of pulmonary aspiration (pooled risk ratio 0.98, 95% CI 0.73 to 1.31), although it was associated with a higher risk for discontinuation of endoscopy (1.99, 1.56 to 2.53). Conclusions: In this comparative cohort study, no increased risk of pulmonary aspiration during upper gastrointestinal endoscopy was observed among adults with type 2 diabetes using GLP-1 receptor agonists compared with SGLT-2 inhibitors within 30 days of the procedure; however, GLP-1 receptor agonists were associated with a higher risk of discontinuation of endoscopy, possibly owing to a higher risk of retained gastric content. In the absence of evidence from randomized trials, these findings could inform future practice recommendations on the preprocedural protocol for patients requiring endoscopy.
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There are no prospective, high-quality studies in the peri-operative setting to support that GLP-1 RAs do not increase risk of pulmonary aspiration in people with diabetes mellitus.
“More case reports continue to be published, and although data from endoscopy settings might suggest that, in people with diabetes mellitus, GLP‐1 RAs might not necessarily increase the risk of pulmonary aspiration, there are no prospective, high‐quality studies in the peri‐operative setting to support this [68].”
The Abstract reports no observed increase in pulmonary aspiration among adults with type 2 diabetes undergoing upper endoscopy and notes an absence of evidence from randomized trials. The Comparison with previous studies section says the findings do not cover other procedures requiring general anesthesia and that additional evidence is needed. It does not establish the broader claim that no prospective, high-quality peri-operative studies exist. (LLM, conf=0.82)
Experimental — accuracy not yet measuredIn the same cohort, the rate of endoscopic procedure interruption was higher in patients treated with GLP-1 RAs, possibly due to increased gastric contents.
“However, the rate of endoscopic procedure interruption was higher in patients treated with GLP-1 RAs, possibly due to increased gastric contents.”
From Delayed gastric emptying induced by glucagon-like peptide-1 receptor agonists and its implications for perioperative risk during anesthesia (2026) · cites this paper as [47]
In an analysis of 43,365 individuals from two US healthcare databases, GLP-1 RAs do not elevate the risk of pulmonary aspiration during upper gastrointestinal endoscopy in patients with T2DM compared to SGLT-2 inhibitors (pooled risk ratio 0.98; 95% CI 0.73 to 1.31).
“A comprehensive analysis of 43,365 individuals from two US healthcare databases indicated that GLP-1 RAs do not elevate the risk of pulmonary aspiration during upper gastrointestinal endoscopy in patients with T2DM when compared to SGLT-2 inhibitors, yielding a pooled risk ratio of 0.98 (95% CI, 0.73 to 1.31) among GLP-1 RA users.”
From Exploring the Side Effects of GLP-1 Receptor Agonist: To Ensure Its Optimal Positioning (2025) · cites this paper as [22]
GLP-1 RAs are linked to an increased likelihood of procedure discontinuation, presumably due to aggravated gastric retention.
“However, these agents were linked to an increased likelihood of procedure discontinuation, presumably due to aggravated gastric retention [22].”
From Exploring the Side Effects of GLP-1 Receptor Agonist: To Ensure Its Optimal Positioning (2025) · cites this paper as [22]
In a cohort study of patients undergoing upper gastrointestinal endoscopy, comparing individuals with type 2 diabetes treated with various GLP-1 RAs with those receiving SGLT-2 inhibitors, there was no significant increase in pulmonary aspiration risk.
“In a cohort study of patients undergoing upper gastrointestinal endoscopy, Alkabbani et al. [47] compared individuals with type 2 diabetes treated with various GLP-1 RAs (both short-acting and long-acting) with those receiving SGLT-2 inhibitors and found no significant increase in pulmonary aspiration risk.”
From Delayed gastric emptying induced by glucagon-like peptide-1 receptor agonists and its implications for perioperative risk during anesthesia (2026) · cites this paper as [47]
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- Authors
- Alkabbani, W., Suissa, K., Gu, K. D., Cromer, S. J., Paik, J. M., Bykov, K., Hobai, I., Thompson, C. C., Wexler, D. J., & Patorno, E.
- Affiliations
- Brigham and Women's Hospital (US)
- Harvard University (US)
- Massachusetts General Hospital (US)
- Corresponding author
- Patorno, Elisabetta
- ORCID
- Venue
- BMJ
- Publisher
- BMJ
- Published
- 2024-10-22
- Volume
- 387
- Pages
- e080340
- ISSN
- 1756-1833 (ISSN-L)
- OpenAlex
- W4403639005
- Cited by
- 60
- References
- 47
- Citations by year
- 2026: 21 · 2025: 35 · 2024: 4
- FWCI
- 19.66
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- BMJ (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- PubMed Central (publishedVersion, cc-by-nc)
- Funders
- National Institute of Diabetes and Digestive and Kidney Diseases
- National Institute on Aging
- American Diabetes Association
- Food and Drug Administration
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Airway Management and Intubation Techniques
- Health Sciences › Medicine › Gastroenterology › Gastrointestinal Bleeding Diagnosis and Treatment
- Keywords
- GLP-1 receptor agonists, SGLT2 inhibitors, upper gastrointestinal endoscopy, pulmonary aspiration, type 2 diabetes, endoscopy safety, propensity score weighting, type 3 diabetes
- MeSH terms
- Sodium-Glucose Transporter 2 Inhibitors, Glucagon-Like Peptide-1 Receptor Agonists, Adult, Aged, Diabetes Mellitus, Type 2, Female, Humans, Hypoglycemic Agents, Male, Middle Aged, Risk Factors, Cohort Studies, Endoscopy, Gastrointestinal, Respiratory Aspiration
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