Abstract

Introduction:
Glucagon-like-peptide-1 receptor agonists (GLP1-RA) are a class of medications that have been proven to be useful in the management of type 2 diabetes and obesity due to their ability to stimulate insulin release, reduce glucagon production, slow down digestion, and promote satiety. Despite these benefits, decreasing gastrointestinal motility and slowing gastric emptying can also lead to retention of gastric contents, gastroparesis, and bowel obstruction.

Pneumonia from aspiration is a known complication of gastrointestinal endoscopy due to increased abdominal pressure with gas insufflation during colonoscopy, impairment of gag reflex from anesthesia, and retained gastric contents at the time of the procedure.

Recently, the American Society of Anesthesiology recommended withholding GLP1-RA before surgical procedures to minimize risk of aspiration. However, there is no clear data that supports such recommendation in endoscopic procedures; requiring to withhold these medications before endoscopy may result in delaying and rescheduling procedures and endangering loss of diabetes control. The objective of this study is to examine the association of GLP1-RA with risk of aspiration and, therefore, pneumonia in patients undergoing colonoscopy and/or esophagogastroduodenoscopy (EGD).

Methods:
This retrospective, propensity score-matched cohort study active control design used data from the Veterans Health Administration Corporate Data Warehouse. Data of patients who underwent EGD/colonoscopy procedures during fiscal years 2016-2021 while using GLP1-RA or dipeptidyl peptidase 4 inhibitors (DPP4i), as active comparators, were extracted. A propensity score was created using 60 baseline characteristics encompassing demographics, comorbidities including diabetes’ microvascular and macrovascular complications, laboratory investigations, and the use of other medications. Our two co-primary outcomes were incidence of any pneumonia and incidence of aspiration pneumonia within 30 days of the procedure.

Results:
A total of 59,280 EGD/colonoscopy procedures were performed (22,570 GLP1-RA users and 36,710 DPP4i users). A total of 189 (0.3%) pneumonia and 26 (0.04%) aspiration pneumonia occurred. Mean (Standard deviation [SD]) age of patients was 66 (8) years and mean (SD) weighted Charlson Comorbidity Index was 4.8 (3.2). We successfully matched 15,943 pairs of patients. In the propensity score-matched cohort, 48 (0.3%) GLP1-RA users had pneumonia vs 57 (0.4 %) DPP4i users (OR: 0.84; 95%CI: 0.57-1.23); and 7 (0.04%) GLP1-RA users had aspiration pneumonia vs 9 (0.06%) DPP4i users (OR: 0.78; 95% CI: 0.29-2.09).

Conclusion:
Incidence of aspiration pneumonia or any pneumonia was similar in both GLP1-RA and active comparators groups in patients undergoing EGD and/or colonoscopies. Withholding GLP1-RA prior to endoscopic procedures may not be necessary.

Silvio de Melo

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