to host the last and hopefully very exciting webinar for this evening on behalf of the Association for Bariatric Endoscopy. My name is Reem Sharai. I am the Director of Endoscopy at Weill Cornell Medicine, and I'll be the moderator for this evening. And on behalf of ABE, a division of the ASGE, we welcome you to this evening's presentation entitled Navigating GLP-1 Safety and Anesthesia, Essentials Insights for the ASGE Physician's Statement, and essentially essential insights into what to do with endoscopy. So I also serve as a member of the ABE Advisory Board, and I'll be facilitating the discussion. And for your speakers tonight, we have today Diana Anka, who is my colleague at Weill Cornell Medical. She's a board-certified anesthesiologist and the Director of NORA, which is the Non-Operative Services. She's an Associate Professor of Anesthesiology. We also have Dr. Walter Chan, who is the Gastrointestinal Motility Expert and the Director of the Center for Gastrointestinal Motility at the Brigham and Women's Hospital in Boston. He specializes in, obviously, GI and motility. And then we have Dr. Nirav Dosani, who is an Associate Professor at the McGovern Medical School at UT Health Houston. He's also the Chair of the ASGE Standards of Practice Committee, and he is an Interventional Endoscopist at UT Health Western, and hopefully we'll be hearing from all of them. Before we start, here are a few housekeeping items. There will be a question and answer session at the close of the presentation, so questions can be submitted any time using the Q&A icon at the bottom of your screen. And please do not use the chat box, because this will not be monitored. And this learning event is being recorded and posted on GILeap, ASGE Learning's management platform, and will be available in approximately one week. All attendees will have ongoing access to the recording in GILeap as part of your registration. Sorry, it's a mouthful to speak. At this time, I would like to hand it over to Diana Anka for the first presentation. I will be discussing the anesthesia and GLP-1 receptor agonists. I'll try to decide where we start with all these discussions, what is the guidance evolution, and what are the future directions. So we started in 2021 with FDA approving the new drug treatment for chronic weight management. And from there, the news exploded. New York Times, New York Post, catching headlines, and then the social media followed, anywhere from Facebook, Instagram, graphic photos of gastric content during cases, and so on. Then the Weight Watchers jumped in with the weight loss drug business. And basically, they got into the business, they bought Sequence, which is a telehealth subscription service. And basically for $49 initial consultation and $99 a month subscription, they connect customers to doctors who can prescribe GLP-1 receptor agonists. Guess what? Sometimes we don't know those patients are on those drugs because they are not getting them from their primary doctor. It's not on their charts, so sometimes they have to do detective work. And then our Anesthesia Society, Society for Ambulatory Anesthesia Discussion and Forums, Anesthesia Patient Safety Foundation, and that's something that's very dear to us anesthesiologists. And they started questioning, are there any risks associated with those drugs? And the case reports started pouring in. And that's a very graphic case report to begin with. That's the 50-year-old who didn't go an endoscopy procedure. She had a hysterectomy. She was on semaglutide. No, she was on manjaro. And when they evacuated the stomach after intubation, they got a little bit, but just before extubation, you see this graphic, large emesis of gastric content. And luckily, she was intubated, so she did not aspirate. And then we started seeing case series of association of those drugs with gastric residual during NGDs. And basically, all those case series show there is a significantly higher residual gastric content on patients taking GLP-1 receptor agonists compared with the ones not taking. And more case series in patients on and not on this medication at about five times incidence of residual gastric content. And then we move on to the American Society of Metabolic and Bariatric Surgery. And it's always a question, are patients who are obese at higher risk for aspiration compared with the non-obese patients? And basically, the residual gastric volume, the pH, and gastric emptying times are similar when all other things are equal. However, prior bariatric surgery and history of GERD are associated with higher risk of aspiration. However, routine prophylaxis, preoperatively, it's not recommended if, and rapid sequence are not recommended if all other things are equal. There is, however, limited data to discuss the risk of carbohydrates, which will allow up until two hours preoperatively. So there's a lot more that we need to know. There are a lot of anecdotal reports and concern of delayed gastric emptying. And of course, the presence of adverse gastrointestinal symptoms, nausea, vomiting, abdominal distention in those patients, which are predictive of increased residual gastric content. And all of those segue into the American Society of Anesthesiologists consensus based on preoperative management of patients taking those medications. And that's a guidance. So of course, that's less strength than guidelines. And basically, they recommend at that time in 2023, in June, that patients who are on daily doses should hold on the day of procedure. And those who are on weekly dosing, withhold for a week. And there was irrespective of the indications of GLP-1 receptor agonist medication. And then day of procedure, an assessment between the proceduralist and the anesthesiologist of GI symptoms and had they withheld or not those medications. And if they had severe symptoms, nausea, vomiting, bloating, and so on, consider delaying elective procedures and discuss the concern of risk of aspiration with both patients and proceduralists. If there were no GI symptoms, then basically, end of medication loss withhelpers will proceed with no change from a regular case. Of course, the problem was no GI symptoms, but the medication has not been withheld. So then proceeded to false stomach percussion. As you can imagine, I already outlined several scenarios. And as different patients are on different medications and they had different other comorbidities, a bit of a confusion and a bit of a spray of case cancellations ensued that served no one basically. And then those are some of your society and other society guidelines, but basically the consensus is there is no data to support stopping those medications for elective endoscopy. So where do we stand? More discussions, more discussion among societies, more discussion among proceduralists and anesthesiologists, and again, more case cancellations. Anesthesiology is the Journal of American Society of Anesthesiology, and basically, they looked at an editorial view. Yes, aspiration is the big bad wolf for anesthesiologists. Increased morbidity and mortality. And of course, diabetic patients are known to have delayed gastric emptying, but it's few data available to actually quantify and compare. And in this prospective non-inferiority study of 180 patients fasting using bedside ultrasound, gastric volume was not higher in diabetic versus non-diabetic patients. So the frequency of false stomach was similar between the two groups. That's important and it's good to know because there are practitioners and there's this anecdotal view that diabetic patients should undergo rapid sequence and so on. Well, it's not true. I'm not going to discuss this because my co-speakers will discuss that on a next talk, but looking at all the data that is coming in, both case reports, gastric ultrasound, case reports, meta-analysis, we are facing now that 2024 multi-society clinical practice guidance for safe use of those medications. And we see names here that are on this panel and our moderator and representatives from American Society of Anesthesiology. And basically, they look at several recommendations. And I hope it's not more confusing than the previous one, but it's basically a standardized preoperative assessment of delayed gastric emptying and it's yes or no. So if we have symptoms, then either due to recent dose increase, higher dose, weekly medication, or medical conditions beyond those medications, then we have to do a selective preoperative assessment of those patients and not one size fits all. So continue the GLP-1 receptor agonist preoperatively if there is no concern for delayed gastric emptying. And if there is risk of delayed gastric emptying, then recommend a clear liquid diet only the day before the procedure and evaluate the feasibility of those medications for bridging in diabetic treatment. And the day of procedure, when we see the patient, when we discuss with our colleagues proceduralists, if all is well, proceed with normal, no concerns, no delayed gastric emptying precautions. If there is a risk of delayed gastric emptying, point of care ultrasound, rapid sequence, and pretty much minimize the cancellation of cases. And that's really important because it brings home the safe continuation of those medications. Again, looking at which phase of those medications those patients are and assess. So now we're talking about a gastric ultrasound that we'll see in all those guidance. And the wording that's used is consider gastric ultrasound. Well, why consider it? And the data is there. And this is a paper from 2019 that adds to a growing body of literature that supports the role of gastric ultrasound to inform the aspiration assessment at a bedside and guide anesthetic planning. So the data is there. Now, why use it for those patients? Well, we have to use it because, again, we're very scared of aspiration pneumonia. It allows us to assess the volume, the nature of the gastric contents, and ability to evaluate the NPO status and risk stratified of patients because ultimately comes down to that. And it's really not so much matter for the general anesthesia of endotracheal intubation, but for those procedures, most of the gastroenterology procedures are performed under deep sedation without a secure airway. So it's basically general anesthesia without a tube. And it might change our anesthetic type. It might change our plan. And it might add to the case overall and might slow down the workflow. Well, how to learn it? Is it that easy? The American Society of Anesthesiology does have a course. I can tell you it's sold out for all those meetings. It's almost impossible. I think you have to stalk that website in order to register because obviously it's clear that everybody took to the gastric ultrasound trying to learn. There are institutional courses. Our department is trying to have an internal department course to familiarize our colleagues and all of us with a gastric ultrasound. And when available, why not? But if it's not available, if you don't have a core of people performing that, then when in doubt, full summer precautions, aspiration prevention, rapid sequence induction will basically be the way to go. So holding those medications might not be necessary as we see. It's very important to stratify the patients and not treat everybody the same. Clears for 24 hours, pre-op, decrease the aspiration risk, gastric ultrasound if available, but not for every institution, not for every practice. And the trial decision is talk to the patient, talk to the proceduralist, discuss the risk, and then make a final decision. And I think I will stop sharing now. Thank you very much. Thank you. I was just thinking in my head as I was listening to this that it's always great to have you as a partner. It's always important to have an anesthesia partner with all of this because, you know, guidelines change. They change very rapidly, but it's really, really important, as you said, to assess, you know, the symptoms, the phase of medication, and the urgency of the procedure. So we'll definitely touch upon this in the Q&A. And so thank you very much, but we're going to move on to Dr. Walter Chen, who is going to share his screen hopefully, but we're going to, he's going to talk to us about the motility and the GLP-1s, and sort of that's where the biggest controversy is coming into play. So Walter, take it away. Thank you. It's great to be here and having this important discussion. So I'm going to talk a little bit about GLP-1 and how it affects motility of the foregut. So these are my disclosures. So I'm going to start with talking a little bit about the basics of what GLP-1 is and how these hormones affect our gut function. So GLP-1 belongs to a class of hormones called incretin hormones. These are generally stimulated by meal ingestion. GLP-1 is secreted by epithelial intestinal L cells, generally in the ileum and the colon. There's some other type of incretin hormones that has similar function, which is the glucose-dependent insulinotropic peptide, or GIP, which has also been leveraged for the same, similar purpose in controlling diabetes and also weight loss. And it's secreted by the L cells and K cells in the more proximal small bowel. Receptors of these hormones are expressed in the gut, in the pancreas, in the brainstem, hypothalamus, or other vagal, afferent nerves, which can impact a lot of gut function and also sensation of satiation and appetite. First of all, how does GLP-1 affect glycemic control, which is the first function of these medications that have been introduced? It generally impact glycemic control by affecting pancreatic islet cell functions. In the beta cells, it increases insulin secretion. For the alpha cells, it reduces glucose secretion. It also has been shown to increase insulin sensitivity, which reduces hepatic gluconeogenesis and also enhance muscular glucose uptake and storage to help reduce blood glucose level. And these are a list of the different types of incretin agonists that's been introduced, both short-acting and long-acting GLP-1 receptor agonist agents, as well as some dual-incretin GIP and GLP-1 receptor agonists that's been introduced as well. We know that these agents have impact on diabetic blood glucose control, has been shown to result in significant improvement in glycemic control compared to placebo for type 2 diabetics in all formulations by decreasing hemoglobin A1C levels as well as fasting plasma glucose level. Also has been shown to result in reduction in body weight compared to placebo in this population. And even in non-diabetic, it's been shown to result in significant reduction in body weight compared to placebo in both daily and weekly formulations of the medication. And also has been shown to reduce fasting blood glucose level, systolic and diastolic blood pressures. It has also been shown to improve other cardiometabolic outcomes compared to placebo among type 2 diabetics, including treating hypertension, hypercholesterolemia, hypertriglyceridemia. But despite all these benefits, one of the main adverse effects of GLP-1 agonists are the GI adverse effects. And GI symptoms represent the major adverse effects of these medications, most commonly nausea, vomiting, altered bowel habits. It has been shown to help decrease appetite. And these digestive symptoms may also be one of the contributing factors to the weight loss effect of the medication. So these symptoms are sort of in some ways leveraged to help induce weight loss, but also can be what limit the use of these medications as well. So how does it actually work? How does GLP-1 actually work in affecting satiation and maybe energy intake? There have been one study, early study that's been done, where a group infused GLP-1 versus placebo in 20 healthy individuals as they ingest a test meal. And compared to placebo, when GLP-1 was infused, it has been shown to increase satiation, increase fullness, as well as plasma insulin after the test meal. It has also been shown to decrease hunger, food and energy consumption, plasma glucagon and blood glucose level compared to when placebo was infused. So it seems like infusing this hormone and higher level of this hormone actually help increase fullness and decrease hunger and also help increase the amount of plasma insulin. And in what pathway does this actually affect satiation? Well, first of all, how does meal affect satiation? So when we ingest food into our stomach, our stomach expands, so there's gastric distension, which results in activation of mechanoreceptors along the mostly gastric fundus. This then induces vagal nerve stimulation that affects the brainstem, the nucleus tractus solitarius, which then increase satiation and lead us to decrease food intake. And GLP-1 may affect this process through actions both in the brain and the gut. First of all, it can directly affect gastric function and vagal nerve signaling at the level of the gut and brain-gut interaction. It also seems to have direct impact on the central neuronal processes that are involved in the regulation of feeding. So as you see in this image, GLP-1 may affect gastric accommodation and also the nerve function that feeds back into the brainstem. It also seems to have direct impact in our brain as well. So there might be multiple levels where GLP-1s are acting to affect the fullness and satiation after eating. And looking at the gastric function level, there've been study looking at how GLP-1 impact different level of gastric function. This is one study where 24 healthy volunteers receive either GLP-1 or placebo, and underwent gastric scintigraphy at baseline, at fasting and postprandially. And what was found was that in a GLP-1 group, there was a higher total and proximal gastric volume postprandially, meaning that there's an increase in gastric accommodation after eating among those getting GLP-1. So their stomach is able to expand more to accommodate more food. And this process, this increase in gastric volume by GLP-1 is absent among diabetic patients who have vagal neuropathy. So this shows that maybe the GLP-1 effect on gastric volume is vaguely mediated. So why is that important? Because an increase in accommodation of stomach is often associated with slower gastric emptying. So when food gets to our stomach, if our stomach is able to expand more to accommodate this food, then generally this higher total or proximal volume would correlate with a slower emptying of the stomach. And it has been shown that exogenous GLP-1 would lead to delay emptying of both solid and liquid in healthy subjects with both an increase in meal retention in the distal stomach as well as a rise in blood glucose, an attenuation in the rise in blood glucose with GLP-1 infusion. There have also been a randomized placebo controlled trial of GLP-1 agonists compared to placebo looking at how they impact gastric function. And in one trial, in this one trial, varicotide was found to be associated with an increase in weight loss and satiation compared to placebo in patients with obesity. And the half time of emptying on gastric emptying saturated rates that was performed was also prolonged in the varicotide group compared to placebo. Interestingly, when the gastric emptying was measured at five weeks into the trial and at 16 weeks, the gastric emptying was actually shorter at 16 weeks compared to the five week point after initiation of therapy. So maybe there's also a tachyphylactic effect of the medications where over time, this delay in emptying might be blunted as patient take these medications for longer. So exactly how much do these GLP-1 agonists delay gastric emptying? We saw this one trial that we just talked about where there's a delayed gastric emptying half time. We actually did a meta-analysis where we tried to look at all the randomized placebo controlled trials of GLP-1 agonists and try to estimate how much of the gastric emptying delay is there among all these medications. And what we found was that there was a poor delay in gastric emptying half time on scintigraphy for solid emptying of about 36 minutes. And when we also looked at liquid emptying, which is represented by the maximal time on these acetaminophen absorption tests that's often employed in these placebo controlled trial, we saw no significant delay in liquid emptying among GLP-1 agonists. So it seems like there's some delay in emptying. Maybe the impact, the actual absolute value of delay is not as much as we initially thought. And it seems like solid food emptying is the one that's most impacted. And it seems to be minimal impact on liquid emptying itself. Other than gastric motility, GLP-1 may also impact intestinal motility. There've been some study looking at colonic contraction and it was found that when exogenous GLP-1 was applied, there's an inhibition in colonic contraction amplitude in peristaltic function. So seroso GLP-1 relaxes these colonic smooth muscle by decreasing this contraction. And this effect was inhibited by GLP-1 receptor antagonists. So these seroso GLP-1 may actually slow colonic motility and peristalsis. Whereas endogenous GLP-1, they're secreted by the luminal L cells actually accelerate proximal colonic motility. So luminally applied GLP-1 has been shown to accelerate propagation of these peristaltic wave in the proximal colonic segments. So it seems like GLP-1 depending on where it's applied, where it's infected on the colonic smooth muscle may both relax and slow motility or actually accelerate contractility in the proximal colon. And these might be one of the reasons where GLP-1 patients may develop diarrhea or sometimes they actually develop constipation as well. And these effect of GLP-1 and GLP-1 motility actually has been leveraged for management of symptoms. There have been one study looking at actually IBD patients who are post colectomy and with ileal pouch. And oftentimes these patients develop high bowel frequency. And there've been some study that have shown that these patients who had colectomy had a low GLP-1 level. So there was a small study out of UNC that did a pilot study where they showed a decrease in bowel frequency in these post colectomy and ileal pouch patients who were treated with loricotide. So perhaps the impact of GLP-1 GI motility can actually be used for management of a different type of GI symptoms. And I think one question we often have is especially for people who are starting with GLP-1 agonist if they do develop these symptoms, what do we do? We know that nausea, vomiting, constipation, diarrhea, changes in appetite and satiety are the most common symptoms associated with the use of these GLP-1 agonists. And we know that there are many different underlying mechanism that we just talked about that can be contributing to these symptoms. Whether it's delayed gastric emptying, changes in gastric accommodation, maybe an altered intestinal motility where we talked about. We talked about impact on central control of appetite and feeding, or effect on these gut-brain interactions or neurosensory input of the GI tract, right? So maybe we can target some of these mechanisms to help manage these GI side effects of GLP-1 agonists. And oftentimes it needs a personalized approach, whether a conservative approach where basically observe these symptoms. And oftentimes because of a tachylophyllactic effect, maybe these symptoms improve with persistent use, maybe changing the regimen, starting at a lower dose in titrate or deescalate, or maybe using different pharmacotherapy like antiemetics, bioregimen, promotility agents or neuromodulators to help treat the presenting symptoms. And the main topic of this session is talk about per procedural consideration. So what do we know about the procedural risks of GLP-1 agonists use? And this was discussed a little bit in the last talk. What we know so far is that we know in a lot of the study that patients who are GLP-1 users have a higher likelihood of having some evidence of increased gastric residue in upper endoscopy. Although a lot of times these amount of gastric residue tend to be small. We know that there's some delay in emptying of solids as our meta-analysis has shown, but seems like likely mild relative to pre-procedural fasting time. There seems to be no or minimal delay in liquid emptying. And there had also been study where patients who was getting a concurrent colonoscopy who are on a longer clear liquid diet and bowel preparation had a smaller amount of gastric residue. And in many study that have been done, large and small study, there had been no clear evidence of increased respiratory complication related to these GLP-1 agonists use. And there's actually been a meta-analysis that's shown that. So I think, you know, some of the take-home points here from my talk, we know that the fact of GLP-1 agonists on the GI tract function and symptoms may be due to different mechanisms, whether it's dysmotility, central impact on satiety and appetite and altered gut-brain interactions. Because of that, there might be different ways we can use to manage symptoms, whether by adjusting medications, conservative management or using pharmacotherapy to target these symptoms. And perhaps a multidisciplinary approach to pre-procedural GLP-1 usage management are necessary as the respiratory complication risk appears to be low. So we might need to balance the risk and the benefit of the procedures. And maybe this can be further modulated with a clear liquid diet prior to procedure and may not need to hold these medications given some of the more recent data that's come out. Thank you. Thank you very much. And so on the heels of that conversation and the anesthesia conversation, we sort of all got together and we were talking about the latest data and the need for some real studies to come out in a sort of a concerted effort. And there was no better person than to lead us than Dr. Nirav Dasani. So he'll be talking to us about our GLP-1 publication, how we did it, what we did it and how he herded us into writing this paper at such a short amount of time. Thank you. Yeah, thank you very much. So my job is to kind of take you behind the scene what we did and how we did it. I will go over our methods and findings. So our first task was to find a panel members. So our panel consisted of gastroenterologists. There were six gastroenterologists who were expert in bariatric endoscopy. They had a lot of exposure doing endoscopy in patients on GLP-1. We had three gastroenterologists who were experts in guideline developments, including myself. We contacted two anesthesiologists. Our criteria was to make sure that they have expertise in out-of-OR anesthesia. So they are providing anesthesia in the GI lab and they are also considered content experts in this field. We had two endocrinologists. They were both considered content expert in this field. And you already heard from Walter Chan, who is a world renowned motility expert. So we were truly lucky to have this dream team of panel together. Then our job was to just use this panel member together and leverage everybody's knowledge. So our first meeting, so we use a modified Delphi process. So what goes on in this meeting is that you get a group of experts together and just have a very open discussion. So we had a very open-ended discussion. We asked different people that what we should do in different scenarios. And what came out of that one, one and a half hour meeting is that we need to look at different patient care scenario. Are we doing elective endoscopy or emergent endoscopy? What type of GLP medications patients are on? Did patient actually follow the instruction? What were the instruction given to the patient prior to endoscopy? And on the day of endoscopy, are there any sign and symptoms suggest you have delayed gastric emptying or not? And do we have expertise to do this point-of-care ultrasound? And after this, we design a questionnaire. We send all the questions to all the experts and let them just answer in different scenario what they think we should be doing. Then what came out of this meeting is that there are three different patient care scenarios. You are doing emergency procedure in hospitalized patients. You are doing outpatient endoscopy, but these are time-sensitive outpatient endoscopy, meaning if you don't get it done within a week, patient may end up in hospital. One of the example would be that patients who have a biliary stent with a sign of fever or itching, and, you know, stent is getting obstructed, and you want to get patient in for a procedure. And it's a truly elective procedure, such as screening colonoscopy or screening for Barrett's esophagus. Then in the modified Delphi process, we also did a thorough literature review. After first round of voting, we all get together. We look at the results, and then we actually provide a detailed review of literature. We had discussion again. We had second round of voting, and then we looked at where our consensus is. Our threshold was to get at least 70% consensus among the members to come up with a guideline. So the first thing that we all agree that at the end of the day, patients are also very important stakeholders in these discussions. So what we end up recommending is that there has to be immediate pre-procedure evaluation of GI symptoms, which could be suggestive of possible delayed gastric emptying for all patients on GLP-1 receptor agonist. This includes symptoms of severe nausea, vomiting, regurgitation while lying supine, abdominal bloating, abdominal distention, and abdominal pain. Now, these are not very specific, but if a patient has one of the symptoms and they are on GLP-1 receptor agonist medication, there has to be some discussion. We also recommended that maybe we should be discussing their potential risk for aspiration with all patients who are on GLP-1 receptor agonist undergoing endoscopic evaluation. Then let's look at with a different patient care scenario what we should do. So you are taking care of patients who is in the hospital and needs emergent endoscopy. So in that scenario, we should not be delaying required endoscopy, maybe consider anesthesia consultation, inform patient about risk of aspiration. On day of endoscopy, look for if there are any sign and symptoms for delayed gastric emptying. And if it is, maybe we do full stomach precaution. If it's not, we do point of care ultrasound if it's available. And then maybe let's have patient, GI doctor, and anesthesia, all of us work together and have a shared decision-making how you are going to proceed with this procedure. But good idea is to move forward and do not delay the required endoscopy in a hospitalized patient. Now let's look at what you do for time-sensitive outpatient endoscopy. Again, it should not be delayed. If you are setting allows, maybe consider anesthesia consultation, inform patient about risk of aspiration. Maybe good idea here based on all the data Walter shared with us that 24-hour liquid diet prior to procedure would be a good idea. Hold GLP-1 agonist medication on day of the procedure for those who are on daily dosing. Again, always look for symptoms suggestive of delayed gastric emptying. And if it is, again, we proceed with a full stomach precaution. If it is not there, but you have ability to do point of care ultrasound, then that would be a good idea. Otherwise, let's move forward with shared decision-making. How we approach elective endoscopy? So what you need to do, again, is that patient needs to be informed about risk of aspiration. 24-hour liquid diet would be a good idea. Those who are on a daily dose, let's hold the medication for a day. Those who are on a weekly dose, let's hold medication for a week and look for symptoms of delayed gastric emptying. And if they are there, maybe we do consult anesthesia, point-of-care ultrasound. And in this scenario, this is an elective procedure and patient have symptoms suggestive of delayed gastric emptying. Maybe we consider rescheduling. If they do not have any symptoms, then we can proceed with moderate sedation or anesthesia-directed sedation. You may also encounter scenario where patient did not hold the medication at recommended time interval. And in that scenario, again, considering anesthesia consultation may be a good idea. We also discussed that what happens in a patient who are diabetic and you are going to hold this medication for a week because we all see that frequently this patient come in, they have a very high blood sugar level and because of that, endoscopy get canceled. So in this scenario, working with your endocrinologist and considering a bridging therapy with other anti-diabetic medications would be a good idea. Now also want to touch base on SGLT2 inhibitors. These are sodium glucose co-transporter inhibitors. Some of the common brand names, sorry, I'm using a brand name, is Giardians and Farsiga. But what happens is that if patient do not stop this medication, patients are addressed to develop something called euglycemic decay. This is diabetic ketoacidosis in a setting of SGLT2 inhibitor. And what ends up happening is that most of this patient has a near normal blood glucose level, but they do have anion-gap metabolic acidosis. Colonoscopy, in cases of colonoscopy, euglycemic decay has been reported and it's mainly because of prolonged fasting and bowel prep. So ASG suggests that holding SGLT2 inhibitors at least three to four days before elective endoscopy procedures. And if patient did not hold and if it's elective procedure then maybe consider rescheduling and if you do not want to reschedule at least obtaining basic metabolic panel before the procedure to look for anion gap acidosis that would be a good idea before proceeding with endoscopy and putting patient at risk to develop diabetic ketoacidosis. Thank you. Thank you so much. So there was a lot to unpack there and I think a lot of it is based on the acuity of the patients and I think they all sort of take that into consideration. So at this time obviously all our experts have come on so please go into the question and answer session if you have any questions. Please click on any of the answers. Sorry. Please ask us any questions. So I guess I'll start first while we're waiting for some of the questions and this really goes to all of you. How have you seen the process with GLPs in your institution? It went from probably cancelling all cases to now a flavoured discussion. What are you seeing? Walter I'll start with you. Yeah no I think we start it went from I think a more conservative approach. I think there was a lot of discussion and some cancelled cases to initially I think our institution came up with our own policy that was a little bit more on a conservative side to I think now with more recent guidelines and data and some of these statements where I think we're leaning towards more definitely not cancelling cases, take extra precautions for patients who are at a little higher risk, generally requiring at least 24 hours of clear liquid diet prior to the procedure and maybe a little bit less strict in requiring everyone to hold their medications. I think our approach now is leaning towards that. And Nirav what happens with you? Yeah I can also tell you six months ago there were multiple cancellations that patients who are on this medication come for elective procedure no symptoms and that was just a blanket cancellation that on this medication we cannot continue it needs to be rescheduled. I think with the effort that we have put in and so as other societies now there is a lot more interdisciplinary discussion. I think everybody now understands that true risk lies somewhere in middle. We know that many times there could be retained gastric content but that not necessarily transpires into true aspiration risk also. So now it has become much more patient-centric approach that we all work together and do have a shared decision making and decide to proceed. I think outpatient clinics also we all now very actively scanning and looking through if the patients are on this medication. So in general now GI clinics we are doing a little bit better job in identifying patients who are on this medicine and giving them proper pre-operative instructions as well. So I think a lot of institution, our institution has a very standardized protocol also so I think those also have come about. So I think overall I feel like we have strike a right balance in getting the endoscopy in a timely manner and safely for all our patients and overall it's been very pleasant journey compared to where we were six, seven months ago versus where we are now. It's really nice and refreshing to see that once all societies, all stakeholders come together and work together we can come up with the right decision for our patient. Very nicely put and Dr. Anca you're like our arbitrator when someone wants to cancel a case I call you so tell us about that experience. Well it's been a journey for us as you know Reem and our institution has just implemented what in the last month. We sat through numerous meetings among you know we are large healthcare system so we eventually decided that it's very difficult to hold those medications to make patients hold it. Getting the information to them not knowing they're on that medication so we decided not to require it but just suggested but put everybody on a 24-hour clear diet that it's shown in multiple studies to be somewhat protective and I think of course when that happens and they you know they come to the day of procedure we look for symptoms and we have a discussion and I think it's not so frequent now that we have to even have the discussion should we do the case should we not do the case because if they're unclear they should be okay. Now one of the questions is how do we implement for especially for open access procedure. I think there has been a challenge but I think Reem spearheaded efforts to to have those two weeks ahead of time do like a screening of those patients so hopefully identify those patients who are on that medication and distribute to the information and the guidelines and then as far as gastric ultrasound it's so different between institutions. We do have a core of people in our institution in our department who are proficient with gastric ultrasound. There aren't that many of them so they're not always available. We're trying to get probes and educate so we're going to start a course to more of us. I'm not personally comfortable with that but I'm I started to look around that I'm planning to take this course too because I think it's useful. You know one of the questions that comes up and I've been to conferences is what is the liability or the legal implication that you do a gastric ultrasound and you clear that patient but then they go ahead and aspirate and you know there's no right answer. I still think it's better than nothing and I think the more of us learning cannot be a bad thing. I think it can only help. Yeah I agree and then what I wanted to touch upon and I wanted to see if any of you kind of use the guidelines or use what you said in your talk about the phase of the medication, when did you start your GLP1s or the symptoms that you may have because I think one of the questions that I just saw in the panel in the question and answer thing is that if what about opiates or if you're diabetic or if you have gastroparesis. I mean there are all these other conditions that kind of do the same thing so what do you do differently? I would say for us we don't distinguish between different formulations of the GLP1 and just like we don't really have a blanket policy to hold opioids or do anything that's significantly differently for patients who have known gastroparesis. We don't really do anything differently currently for the different formulation GLP1. One thing I have to say that is it's part of the study we did when we tried to meta-analyze all these different randomized controlled trials. We try to look at whether or not there's a difference in terms of gastric emptying when we look at different time points from the start of medications because of this questionable tecleflectic effect and we didn't really see any significant effect there consistently so you know does it make a difference if they just started a week ago versus started you know four months ago with regards to actual aspiration risk. I'm not sure there's enough data to actually tell us that so right now we basically mostly don't ask don't require patients to hold the medications regardless of when they started and what formulation and just like what Diana said you know depending on what symptoms they have when they come in maybe other risk factors we may have a discussion on the day of but we don't really you know kind of just ask everyone to hold regardless. Do you ask them to be on clears 24 hours prior? Clear yep they all need to be on clears 24 hours prior yep. And we've updated our preps to that extent. Nirav have you done the same thing? Yes same. So Nirav I guess there's a question is what you just said the guidelines or guidance or how would we put the ASGE into this framework? Right and you know whenever we write a guideline we just want to strike a balance that we want to have something that is user-friendly, patient-centric and do no harm is always on the top of the list so if somebody really needs endoscopy for diagnostic or therapeutic evaluation obviously we don't want to delay it but we also want to do it very safely and that's when having some guidance around it that how you approach this condition. I think six seven months ago almost everybody was getting on this medication some patients were not even on this medication through proper physician prescribing so you as a physician may not even know or they may not tell you what dose how long they've been taking and all of that so that's when and we have seen it we have seen during endoscopy large amount of gastric residual volume so the concern is real but I think as we move forward with a little bit more practical approach that yes just spend a little bit time with patient what medications are they are on on day of procedure look for sign and symptoms and if they have sign and symptoms then let's have multidisciplinary decision discussions with anesthesia patient ourselves and if procedure is needed let's move forward but do it in a safe manner I think a lot of this truly impacts that if you are in a ambulatory surgical care setting and you are the one actually giving moderate sedation you do not have any anesthesiologist backup and if me as a GI doctor if I go in an aspiration event is there during moderate sedation do I have enough expertise to do emergent intubation and save patients and all of that so I think that's when in those setting the definitely spending a little bit more extra time with a patient and doing it safely truly can help you and your you yourself and your practice everybody and so I guess that ties into the following question is it only for conscious sedation or just general anesthesia or now they call it general anesthesia without intubation I guess so I guess it applies to to everyone what do you feel Diana about the sort of guidances that we're sort of coming up with that if you want to proceed proceed with caution either lighter sedation or an RSI or have a discussion with anesthesia with the patient and I feel like when we say patient-centric approach you can kind of frame it to the patient the way you want right if you'll say the risk of aspiration is going to be super high and you're going to end up in pneumonia in the ICU or you may have some food but we're going to give you lighter sedation and then just pull out if we find a lot of food can change the way things proceed of course the way we phrase all that we do and you know that's a point of contention and you know it's variable among practitioners everywhere I'm sure lighter sedation allows the patient to protect their airway versus deeper sedation does not and without an endotracheal tube they are more likely to to aspirate as you know I'm not a belief to just you know scare patients because it's very easily done you know it's how you phrase it I mean all you have to do is like look worried and you know use the phrases and the patient will say well I don't want to take this risk so I think that's a fine line that we have to hone among ourselves you know and decide if really needs to be done it should be done and we don't have to be like fear-mongering with the patient and have them you know run for the hills because I have seen patients who are not on GLP-1 receptor agonists and they had content and aspirated and then patients who were on GLP-1 and had food at APM and they had an empty stomach as Walter was mentioning you know I mean it's not necessarily a given so yeah lighter sedation allows more airway protection from the patient they can cough they can you know protect their airway propofol has a low safety margin in terms of both respiratory and hemodynamics once you use propofol it's again we call it general without a tube because they out cold but they can protect their airway. And I guess there was a question there just asking about the difference in moderate sedation versus propofol I think Nirav maybe because you have both what do you I think we when we were doing the guidelines you were sort of saying that if what would happen if if like an anesthesiologist cancels can you end up doing it under under moderate sedation or how would that work? Right and and I think that's when truly true team multidisciplinary team and it's the same team you are working well together so you know you and Diana work so well all these years together and we also have a dedicated out of OR anesthesia team you look at it their approach is very different that comfort level is different they know what GI endoscopist do how quickly they can finish certain procedures so you will see a clear difference that anesthesiologist will never been in GI lab and they end up in GI lab even for reflux or gastric bypass they're like intubate everybody versus experience anesthesiologist will tell you that hey let's if even if it's a concern let's quickly put a scope and if we see large residue then we can obviously intubate and all of that so I think I think everybody should strive to have a team that works well together and I think that that team always have better outcome we had this very intense debate and discussion when we were coming up with the guideline that what happens that if anesthesia did not feel comfortable and you think procedure is needed and you proceed with moderate sedation now obviously whenever any in a medical decision making one team member is not agreeing and other member wants to do something yes as long as patient agrees the risk you can do it but then you are putting yourself as a medical legal liability if something goes wrong what I have found is that as long as there is a good discussion and good explanation between GI doctor anesthesiologists and patients you usually can come up with a very clear consensus that let's proceed this way so I always advise my team members that we should not ever be in a position that one says do this and other says no we are going to do something different that's never a good outcome for patients so if I'm a patient I want both my GI doctor anesthesia on same page I don't want them one said do this and one said do that yeah that's that's absolutely true um and well said Walter yeah yeah I think I think um I agree with what was said I think the one thing I just really want to point out probably one last thing I want to point out uh I think emphasizes that uh even compared to a year ago there's been a lot more experience in using these medications I think we've seen a number of different publications that have come out on this topic both in meta-analysis smaller study in endoscopy to larger more population-based even surgical patients and I think the consistent theme is that you know despite a lot of these concerns the actual risk of respiratory complications in all these populations in all these cohort had not been really significantly higher amount these users compared to non-users as long as a well-controlled study where you're comparing higher risk patients to higher risk patients where you're comparing diabetics to other diabetics using other medications so I I think um this is certainly something we need to pay attention to but we also need to pay attention to like high quality data that as we accumulate more experience in terms of what the actual risks are and and and not really um overreact in some ways yes um so in the last like minute or so maybe 30 seconds each I uh just want to hear closing thoughts and and I love your don't overreact do what's best for the patient is probably like the key thing here but um Diana take it away I mean I think having a team and knowing your procedural is just as you know your anesthesiologist is important I would point out as Nirav mentioned you know when you are in a surgery center and something happens then they have to be admitted to a hospital and you don't have a rescue I think I'll be more cautious there but I think we make such great strides and I think there is a future for the gastric ultrasound so stay tuned for that because I think you'll see more of us becoming more comfortable doing that and that will help a lot I would like to see some more studies there are some studies on gastric ultrasound and endoscopy what happens at the same time so we had study from our center published in JAMA that what they saw in gastric ultrasound what we saw in endoscopy but I would like to see some large-scale studies to see what the correlation is and I would also like to see some true randomized trial that we do not stop any GLP-1 for elective procedure just put them on 24-hour liquid diet versus we stop it and then we look for retained gastric content aspiration risk and I think that clinical trial will truly put this question to the rest Yeah and I agree and I think probably the important thing is how do we identify that probably a small population or patient where this is truly a significant risk and change you know how we practice with that small group patient and how what are some of the risk factors we can identify. Well thank you so much for everyone and thanks so much for joining us today we hope this information is helpful to you and your practice and as a reminder you can access the beautiful recording of this webinar by logging into GILeap by going into learn.asge.org and we would like to thank our ABE chair Dr. Allison Shulman and Dr. Mariana for all their hard work in making this event come together and if you have nothing to do on May 1st you should come to the ABE educational event our annual course which will oh sorry it's May 2nd which will be held on Friday May 2nd at DDW so hope to see you all there Thank you again. Thank you. Thank you. Bye-bye.

Bariatric Endoscopy

GLP-1 receptor agonists

endoscopic procedures

anesthesia practices

gastric motility

interdisciplinary collaboration

clinical guidelines

patient education

safety protocols

therapeutic continuity