GLP-1 Receptor Agonists before Sedated Endoscopy: Divergent Guidance, Limited Aspiration Signal, and Operational Implications

Abstract Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are now routinely prescribed for type 2 diabetes and obesity, making their periendoscopic management a daily practical issue for gastroenterologists, anesthesiologists, and endoscopy units. Concern about delayed gastric emptying and retained gastric contents initially led to conservative recommendations favoring temporary drug cessation before elective procedures. However, more recent gastroenterology and perioperative guidance has moved toward individualized risk stratification rather than universal withholding. At the same time, endoscopy-specific recommendations remain more operationally prescriptive than broader anesthesia-oriented statements. This review examines the evolution of guidance relevant to sedated gastrointestinal endoscopy, compares major gastroenterology and perioperative recommendations, and synthesizes the available evidence regarding gastric emptying, retained gastric contents, aspiration, procedure interruption, and bowel preparation quality. Although GLP-1 RA use is consistently associated with increased retained gastric contents and more frequent aborted or interrupted upper endoscopy, a reproducible increase in clinically overt aspiration has not been clearly demonstrated. The most immediate burden may therefore be operational rather than catastrophic, including same-day cancellations, inefficient sedation planning, repeat scheduling, and discordance between gastroenterology and anesthesia teams. The central clinical question is no longer whether GLP-1 RAs delay gastric emptying, but how endoscopy units should manage the resulting uncertainty without creating avoidable disruption or metabolic harm. A pragmatic framework should integrate procedure urgency, active gastrointestinal symptoms, dose-escalation phase, formulation type, coexisting motility disorders, procedural setting, and anesthesia resources. In current practice, the most defensible approach is not blanket prohibition but a shared, symptom-based, and operationally aligned pathway that minimizes both aspiration risk and unnecessary interruption of care.