Clinical Bottom Line

Situation	2026 practical answer
Asymptomatic patient, standard fast only	AGA rapid CPU: you may proceed. Residual gastric contents are still more common on GLP-1s. A 24-hour clear-liquid day is safer than a standard 8-hour solid fast.
Elective EGD on a weekly GLP-1	ASGE 2025 suggests holding the weekly dose 7 days, or the daily dose 24 hours, plus 24-hour liquids. The 2026 OCULUS RCT found more clinically significant residual volume when the dose was continued, especially for EGD-only.
EGD plus colonoscopy after a full-day liquid prep	Residual contents drop sharply. Same-day colo is the best available mitigation if the drug was not held.
Nausea, vomiting, distention, or known gastroparesis	Do not treat this as a routine NPO. Consider delay, gastric ultrasound if you use it, or anesthesia with full-stomach precautions.
Urgent or emergent endoscopy	Do not delay needed endoscopy to complete a GLP-1 hold. Use aspiration precautions.

The actual risk is a full stomach, not a pneumonia stampede

GLP-1 and dual GIP/GLP-1 agonists slow gastric emptying. Meta-analyses show more residual gastric contents and more aborted EGDs. They have not shown a clear increase in aspiration pneumonia. That distinction matters. You cancel or intubate for a stomach full of solids. You do not need a myth about epidemic Mendelson syndrome to take the residue seriously.

Standard ASA fasting still applies. It is not enough by itself on a GLP-1

Intake	Usual ASA minimum	On a GLP-1
Clear liquids	2 hours	Keep. Encourage clears. Do not revert to NPO after midnight.
Light meal	6 hours	Prefer a full clear-liquid day before elective endoscopy.
Heavy or fatty meal	8 hours	Not an acceptable last meal the evening before an EGD on a GLP-1.

Gastroparesis, achalasia, and gastric outlet obstruction still need a longer liquid run-in, GLP-1 or not.

Holds vs diet: the societies do not fully agree

Three documents are in active use, and they do not say the same thing:

AGA rapid clinical practice update (2023/2024): If the patient followed a standard fast and has no nausea, vomiting, dyspepsia, or distention, proceed. A liquid day may be better than stopping the drug. Holding one weight-loss dose is optional, not mandatory.
ASGE position statement (2025): Liquid diet for 24 hours in all GLP-1 users. For elective cases, hold daily agents 24 hours and weekly agents 7 days. Get anesthesia involved if the hold was missed or symptoms suggest delayed emptying.
Multi-society / ASA 2024 shared guidance: Joint decision among endoscopist, anesthesia, and prescriber. Low-risk asymptomatic patients on stable doses may continue. Higher-risk patients follow a hold.

The 2026 OCULUS randomized trial (interim, then stopped early) found clinically significant residual gastric volume in 25% who continued the agonist versus 3% who held one dose. The gap was concentrated in EGD-only patients. Patients who also had colonoscopy after a clear-liquid day had no clinically significant residual volume. That is the most useful new number on this page.

A room rule you can actually run

Ask every intake patient about weekly or daily GLP-1/GIP drugs by name (semaglutide, tirzepatide, liraglutide, dulaglutide, and the rest).
Put elective EGD-only patients on 24-hour clears. Holding the weekly dose is reasonable and now has RCT support.
If EGD is paired with colonoscopy, the liquid prep does most of the work. Still document the drug.
On entry, look in the stomach before you commit to deep sedation without a plan. If you see a solid meal, stop. Protect the airway. Do not "just lavage and proceed" in an ambulatory room without anesthesia support.
Do not postpone an urgent bleed, food impaction, or cholangitis case for a 7-day hold.

Antithrombotic holds are a different checklist. See antithrombotics around elective endoscopy.

Selected references

Last reviewed September 20, 2026. Written for clinicians running elective and urgent endoscopy lists. Local anesthesia policy may be stricter than AGA guidance; agree the rule before the patient arrives.

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