Counterfeit and unregulated GLP-1 receptor agonists: an unmeasured variable in emergency department procedural sedation risk

Emergency clinicians are increasingly advised to ask about glucagon-like peptide-1 (GLP-1) receptor agonist use before procedural sedation because delayed gastric emptying may raise aspiration risk. Point-of-care gastric ultrasound studies confirm that a substantial minority of patients retain significant gastric content despite standard withholding intervals, but larger cohort studies have not found a corresponding increase in clinical aspiration events, so existing concern may already overstate actual risk. Current guidance further assumes that a patient reporting GLP-1 use is taking a verified product at a known concentration and schedule. This assumption fails where informal and unregulated supply chains are common: the World Health Organization has documented rising falsified-semaglutide reports globally since 2022, and market-surveillance data show substantial deviation between labelled and actual drug content in products purchased online without prescription. Detailed characterisation of this informal supply remains concentrated in the UK, EU and North American surveillance systems, with no comparable published data from South Asia or other low- and middle-income settings, including Pakistan. We argue this is not a problem specific to GLP-1 agonists but one of unlicensed or informally sourced medication use generally, carrying three distinct risks: unpredictable drug concentration, undisclosed adulterants and patient reluctance or inability to disclose use. We propose a draft framework for evaluation: source-agnostic history-taking that does not rely on brand recognition; use of gastric point-of-care ultrasound, where available, in preference to fixed withholding intervals when a product’s source cannot be verified; and, where ultrasound is unavailable, a more conservative sedation technique rather than routine procedural deferral, given the absence of confirmed elevated aspiration rates even among verified GLP-1 users. We call for a prospective, multicentre study of this framework, powered to detect a difference in either direction, rather than assuming unverified-source use carries greater risk.