Introduction

Pharmacologic therapy is a key component of obesity management, either as standalone treatment or in conjunction with procedural interventions. The role of weight loss medications in the peri-ESG period remains unclear, with questions surrounding whether ESG reduces the need for pharmacotherapy or serves as a platform for combination therapy. Limited data exist on how prescribing patterns evolve before and after ESG in real-world settings. This study aims to evaluate the use of anti-obesity medications before and after ESG, focusing on patterns of pharmacologic initiation and its relationship to weight loss outcomes.

Aims & Methods

We conducted a retrospective review of 236 patients who underwent ESG at Singapore General Hospital between November 2020 and December 2025. All procedures were performed by a single experienced endoscopist using a U-shaped suturing pattern. For this analysis, we examined the use of anti-obesity medications before and after the ESG. Medications included GLP-1 receptor agonists, sympathomimetic agents, lipase inhibitors, and combination therapies. The primary outcome was the proportion of patients receiving pharmacotherapy across timepoints and its association with total body weight loss (%TBWL).

Results

Among the 236 ESG patients, 21.6% had previously used anti-obesity medications, most commonly GLP-1 receptor agonists or phentermine. This group consistently achieved the lowest total body weight loss (%TBWL) across all follow-up points. Compared to medication-naïve patients, their mean %TBWL was significantly lower at 6 months (9.9% vs 17.2%, p = 0.015), 12 months (7.8% vs 13.8%, p = 0.026), and 24 months (4.3% vs 10.6%, p = 0.003). These findings underscore the complexity of obesity care, as even patients exposed to multiple treatment modalities may continue to experience suboptimal outcomes.
After ESG, 37.7% of patients were initiated on pharmacotherapy, most commonly semaglutide (n = 66), including 38 on subcutaneous and 28 on oral formulations, with estimated mean doses of 1.63 mg/week and 13.2 mg/day, respectively. Phentermine and liraglutide were used in 13.9% and 3.0% of patients. Patients who received medications only after ESG had lower %TBWL at 6 months compared to those never on medications (14.0% vs 18.8%, p = 0.027), but outcomes were similar by 12 and 24 months. This suggests that pharmacotherapy may help support suboptimal early responders and mitigate longer-term differences.

Conclusion

Anti-obesity medications, particularly semaglutide, are commonly introduced after ESG to support patients with suboptimal early weight loss. While those requiring pharmacotherapy initially experienced less %TBWL, outcomes equalized by 12 months, suggesting a role for adjunctive treatment in slower responders. Patients who had previously used weight loss medications consistently achieved poorer outcomes, highlighting the challenges of obesity management even with multimodal therapy. These findings underscore the importance of individualized treatment strategies and the complementary role of pharmacotherapy alongside ESG in real-world practice.

Disclosure

​NIL

Introduction

Obesity and type 2 diabetes mellitus (T2DM) represent growing global health challenges, affecting millions of individuals worldwide. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have emerged as a cornerstone in the management of both conditions due to their metabolic benefits, including weight loss and glycemic control. European cohort studies have reported a high prevalence of gastrointestinal symptoms – including nausea, vomiting and early satiety among patients using GLP-1RAs. In parallel, increased rates of residual gastric content (RGC) during upper endoscopy have raised safety concerns, prompting reevaluation of pre-procedural fasting guidelines. However, data on the effects of GLP1-RA on the gastrointestinal (GI) tract in Asian patients is limited.

Aims & Methods

Our primary aim was to characterize a cohort of patients who received treatment with GLP1-RA in terms of their gastrointestinal side effects and presence of RGC during upper endoscopy. The secondary objective was to compare the afore-mentioned variables between 2 groups: oral versus subcutaneous mode of administration. We conducted a retrospective cross-sectional cohort study of 139 Asian adult patients with T2DM and/or obesity who were prescribed GLP-1RAs at a tertiary hospital between 01 January 2022 to 01 January 2023. Data collected included demographics, anthropometric measurements, co-morbidities, GI symptoms and upper endoscopy findings. Upper endoscopy images were analysed and adequacy of mucosal visibility was graded using the POLPREP scale. Patients were further stratified into two subgroups based on route of GLP-1RA administration: oral versus subcutaneous. Statistical analysis compared symptom prevalence and POLPREP scores across subgroups using chi square test, with p <0.05 considered statistically significant.

Results

A total of 139 patients were analysed. 19.4% of patients had GLP-1RA prescribed for T2DM, 21.6% for Obesity, and 58.8% for both. The most commonly prescribed GLP-1RA was Liraglutide (33.8%) followed by oral Semaglutide (28.1%). Majority of patients (66.9%) did not have any GI side effects. The most commonly reported GI symptoms were abdominal bloating (15.8%), nausea (7.9%) and early satiety (4.3%). 13.7% of patients underwent upper endoscopy with 89.5% having a POLPREP score of 3 with no significant complications reported. None of the patients withheld GLP-1RA prior to endoscopy. Upon stratifying patients based on route of administration, analysis revealed that patients on oral GLP-1RAs were more likely to report nausea compared to those on subcutaneous formulations (15.8% vs 5.0%, p=0.03). There were no significant differences in the other GI symptoms or POLPREP scores.

Conclusion

Based on our Asian cohort, these findings suggest that GLP-1RAs have an acceptable GI symptom profile with a potential route-dependent difference in symptomatology. In addition, discontinuing these drugs prior to upper endoscopy may be unnecessary.

References

1. Camilleri et al. Effects of GLP-1 and other Gut Hormone Receptors on the Gastrointestinal tract and implications in clinical practice. Am J Gastroenterol 2024;119:1028-1037
2. Nadeem et al. Effects of glucagon-like peptide-1 receptor agonists on upper endoscopy in diabetic and nondiabetic patients. Gastrointestinal Endoscopy 2024.
3. Jalleh et al. Gastrointestinal effects of GLP-1 receptor agonists: mechanisms, management, and future directions. Lancet Gastroenterol Hepatol 2024;9:957-64
4. Facciorusso et al. Effects of Glucagon-like peptide-1 receptor agonists on upper gastrointestinal endoscopy: A meta-analysis. Clinical Gastroenterol and Hepatol 2024.
5. Romańczyk et al. Scoring system assessing mucosal visibility of upper gastrointestinal tract: The POLPREP scale. J Gastroenterol Hepatol 2022 Jan;37(1):164-168.

Disclosure

Nothing to disclose