GLP-1 Agonists and the Risk of Pulmonary Aspiration during Elective Upper Endoscopy: A Systematic Review and Meta-analysis

Introduction: Glucagon-like Peptide-1 (GLP-1) agonists cause delayed gastric emptying by acting on vagal afferent nerves. Retained gastric contents (RGC) increase the risk of pulmonary aspiration, particularly under anesthesia in endoscopic procedures. This systematic review and meta-analysis aim to summarize the current evidence on pulmonary aspiration in patients receiving GLP-1 agonists undergoing endoscopy. Methods: A systematic review was conducted using Cochrane, Embase, and PubMed from inception to May 2024, including studies and case reports examining GLP-1 agonists and pulmonary aspiration. Data on study characteristics, patient demographics, and GLP-1 agonist use were collected. A pooled analysis of retrospective studies was performed using RevMan version 5.4.1. The study protocol was registered in the PROSPERO database (ID CRD42024595241). Results: A total of five case reports involving six patients and twelve studies including 210,216 patients were identified. Pulmonary aspiration occurred in 143 of 87,691 patients (0.16%) in the GLP-1 agonist group and 149 of 122,525 patients (0.12%) in the placebo group. Notably, three patients experienced aspiration despite stopping GLP-1 agonists more than six days prior and fasting for over eight hours. The meta-analysis showed an odds ratio of 1.23 (P = 0.59; 95% CI, 0.58 to 2.60) for pulmonary aspiration associated with GLP-1 agonist use, which was not statistically significant. Discussion: This analysis did not find a statistically significant association between GLP-1 agonist use and pulmonary aspiration risk during endoscopic procedures. While the findings align with some existing studies suggesting minimal increased risk, the presence of aspiration cases despite prolonged fasting highlights potential gaps in current peri-procedural management. Limitations include reliance on retrospective data and case reports, as well as variability in fasting protocols. Conclusion: The study found no significant association between GLP-1 agonist use and pulmonary aspiration risk during endoscopy. Further research is warranted to develop evidence-based fasting guidelines and optimize peri-procedural management for patients on GLP-1 agonists.