Michael Camilleri, MD, MPhil, DSc

Since 2022, glucagon-like peptide 1 (GLP-1) receptor agonist (RA) use has increased by more than 100%, whereas other obesity interventions, such as bariatric surgery, have decreased.¹ There is an ongoing debate on the gastroenterologist’s role in treating obesity.² Obesity has a profound impact not only on diabetes and cardiovascular and neurologic disease, but also on gastrointestinal (GI) conditions and liver health.² Thus, obesity is a significant risk factor for other diseases like metabolic dysfunction-associated steatotic liver disease, inflammatory bowel disease, and gastroesophageal reflux disease.

As GLP-1 RA use increases, questions about the risk-benefit profile have arisen, especially among gastroenterologists who assess some of the treatmentrelated GI side effects. GLP-1 RA benefits extend beyond weight loss and diabetes control, improving cardiovascular and neurological outcomes as well.³ However, challenges remain. GLP-1 RAs are associated with delayed gastric emptying, which, though generally manageable, raises concerns about rare complications such as aspiration during procedures.^3,4 Despite these concerns, a 2024 study indicates that delayed gastric emptying may normalize in patients over time and rarely, if ever, interferes with clinical practice.^3,4 Moreover, for patients with other GI side effects, such as nausea and vomiting, titration adjustments and slower escalation can be helpful.⁵ According to a review of published data, even though there may be some food retained in the stomach at the time of gastroscopy, the risk for aspiration is extremely low and the examination can usually be completed satisfactorily without having to repeat the endoscopy.³

New multisociety guidelines were released in 2024 on the risk for aspiration in patients on GLP-1 RAs during the periprocedural period, emphasizing balancing benefits of obesity treatment with risks for delayed gastric emptying.⁶ Although there are many benefits with GLP-1 RAs, questions remain about long-term safety, such as potential impacts on muscle mass and heart health, underlining the need for further research.