Holding Versus Continuing GLP-1s, GIPs Before Endoscopy, With Akram Ahmad, MD

Continuing GLP-1 and GIP-1 agonists prior to upper endoscopy significantly increases the risk of clinically relevant residual gastric volume (CR-RGV) that precludes adequate examination, according to findings from the OCULUS trial.1

Data from the single-blinded, randomized controlled trial were presented at the American College of Gastroenterology (ACG)’s 2025 Annual Scientific Meeting by Akram Ahmad, MD, a gastroenterology fellow at Cleveland Clinic Florida, and highlight the benefits of holding a single dose of the medication on CR-RGV risk. Of note, further analysis revealed clear liquids the day prior to endoscopy may eliminate the risk of CR-RGV, regardless of whether the GLP-1/GIP is held or continued.1

With the growing popularity of GLP-1 RAs across multiple specialties in medicine, significant gastrointestinal concerns have also arisen, particularly regarding the effects of these agents on gastric motility and the potential complications they pose for endoscopic procedures. In 2023, the American Society of Anesthesiologists (ASA) Task Force on Preoperative Fasting released guidance suggesting holding GLP-1 RAs prior to the procedure/surgery, irrespective of the indication, dose, or the type of procedure/surgery.2

In 2024, the ASA released updated clinical guidance on the use of GLP-1 RAs prior to elective surgery and gastrointestinal endoscopies, this time in collaboration with the American Society for Metabolic and Bariatric Surgery, American Gastroenterological Association, International Society of Perioperative Care of Patients with Obesity, and Society of American Gastrointestinal and Endoscopic Surgeons. Contrary to the previous 2023 guidance from ASA, the new multisociety guidance published in 2024 asserts that most patients can continue to safely take GLP-1 RA therapy prior to their procedure/surgery and therefore do not need to hold the medication, pending shared decision-making between the patient and procedural, anesthesia, and prescribing care teams.2

“[GLP-1s and GIPs] started surging gradually, and that led to people using them a lot. It's become a real serious question in the preprocedural setting, but there have been no studies to actually address whether to continue it or stop it,” Ahmad explained to HCPLive, citing a lack of concrete evidence used to support stopping or continuing these medications prior to endoscopy.

To test whether holding a single dose of a GLP-1 or GIP agonist prior to endoscopy would be noninferior to continuing these medications for reducing the risk of CR-RGV, investigators conducted the OCULUS trial at 2 tertiary centers. Eligible outpatients on stable maintenance dosing of GLP-1/GIP medications planned for an upper endoscopy were invited to participate and were randomly assigned to either continue GLP-1/GIP agonist therapy or to hold therapy as outlined in guideline recommendations. Both endoscopy and anesthesiology teams were blinded to study group assignments.1

A total of 60 patients completed the study protocol, and an interim analysis was conducted at 50% enrollment as planned. There were no significant differences in baseline characteristics. In the intention-to-treat analysis, CR-RGV was significantly greater in the group who continued GLP-1/GIP agonist therapy.1

Of note, the study was terminated because the Z-value was 2.75, which exceeded the O’Brien-Fleming stopping boundary of 2.5491. Investigators noted there were no cases of CR-RGV in the subgroup who also underwent colonoscopy and were on 1 day of clear liquid diet (0/13 continued, 0/12 held). There were no study-related adverse events.1

“The clinical implication is that continuing the medication doesn't sound like a safe option, because there is at least a 1 in 4 chance that your patient would have a high volume in the stomach,” Ahmad explained. “Maybe in GI it's a little bit safer because we look directly in the stomach, but for other specialties in a preprocedural setting and not stopping GLP-1, there is a high risk and high chance that there is food in the stomach in a high volume.”

Editors’ note: Ahmad has no relevant disclosures.

References

1. Ahmad AI, Ansari Z, Al-Din TJ, et al. Randomized Controlled Trial of Holding Versus Continuing GLP-1 or GIP Agonists Before Upper Endoscopy (OCULUS Trial). Presented at the American College of Gastroenterology (ACG)’s 2025 Annual Scientific Meeting. Phoenix, Arizona. October 27-29, 2025.

2. Brooks A. Endoscopy in the Age of GLP-1 RAs: 2024 Sees New Risk-Based Perioperative Guidance. HCPLive. December 4, 2024. Accessed October 27, 2025. https://www.hcplive.com/view/endoscopy-in-the-age-of-glp-1-ras-2024-sees-new-risk-based-perioperative-guidance