The increasing use of Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) presents a significant challenge for upper gastrointestinal endoscopy (OGD) due to their effect on delaying gastric emptying. Standard fasting protocols are frequently inadequate, leading to limited views and requiring repeat procedures. This study aimed to identify the key demographic, clinical and procedural predictors of endoscopic success in patients on GLP-1 RAs and evaluate strategies for optimizing outcomes.

 We conducted an analysis of a prospective audit database including patients on injectable GLP-1 RAs undergoing OGD in a 6 month period from January to June 2025, across three sites in the UK. Data analysed included demographics, clinical status (diabetes, insulin use, indication), GLP-1 RA type and procedural variables (preassessment, sedation, Nil By Mouth (NBM) duration). Multivariate logistic regression was employed to determine independent predictors of poor views as described by the endoscopist. Outcomes and NBM durations for initial and repeat procedures were compared.

 The analysis included 223 initial procedures. Poor mucosal views were demonstrated in 19%(43/223) of cases. For the initial procedures, 98% of patients followed a standard 6-hour fast. Multivariate analysis demonstrated that demographic factors, BMI, type of GLP-1 RA (Tirzepatide, Semaglutide and Liraglutide), indication and the presence of diabetes with or without insulin therapy were not significant predictors of obstructed views during diagnostic gastroscopy in individuals taking GLP- 1 RA.

Procedural factors showed strong protective trends with the utilization of sedation (OR 0.51; 95% CI [0.24–1.09]; P=0.082) and completion of a dedicated preassessment (OR 0.47; 95% CI [0.20–1.09]; P=0.078) reducing the odds of poor views by approximately 50%.

Thirty-four patients required repeat endoscopy and nine did not as their indication was achieved on index endoscopy. The strategy for the second attempt involved significantly extending the mean NBM duration from 6.19 hours to 14.62 hours (P<0.0001). 91% (31/34) of patients fasting for atleast 12 hours achieved good mucosal views.

In patients taking GLP-1 RAs, standard 6-hour fasting is inadequate in one-fifth of cases, irrespective of patient demographics or metabolic status. The key to ensuring successful endoscopy lies in meticulous procedural optimization rather than patient selection. Dedicated preassessment and critically, extending the NBM duration to at least 12 hours are recommended to ensure adequate visualization and minimize the need for repeat procedures in this high-risk cohort.