Impact of glucagon-like peptide-1 receptor agonists on colonoscopy outcomes: a systematic review and meta-analysis

Ahmad Abdulraheem; Bara Abujaber; Lindsay Ayers; Usman Afzal; Dania Qarkash; Nadera Altork; Qusai Al-Zureikat; Kiandokht Bashiri; Ghaith Almhanni; Peppas Spyros; Won Kyoo Cho

doi:10.5946/ce.2025.137

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Systematic Review and Meta-analysis Impact of glucagon-like peptide-1 receptor agonists on colonoscopy outcomes: a systematic review and meta-analysis: Ahmad Abdulraheem^1,2, Bara Abujaber^1,2, Lindsay Ayers³, Usman Afzal^1,2, Dania Qarkash⁴, Nadera Altork^1,2, Qusai Al-Zureikat^1,2, Kiandokht Bashiri^1,2, Ghaith Almhanni^1,2, Peppas Spyros^1,2, Won Kyoo Cho^3,5; Clinical Endoscopy 2026;59(2):211-222.
DOI: https://doi.org/10.5946/ce.2025.137
Published online: February 13, 2026

¹Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC, USA

²Georgetown University Medical Center, School of Medicine, Georgetown University, Washington, DC, USA

³Department of Medicine, School of Medicine, Georgetown University, Washington, DC, USA

⁴Department of Internal Medicine, School of Medicine, University of Jordan, Amman, Jordan

⁵Department of Gastroenterology and Hepatology, INOVA Medical System, Leesburg, VA, USA

Correspondence: Ahmad Abdulraheem Department of Internal Medicine, MedStar Washington Hospital Center, 110 Irving St NW, Washington, DC 20010 USA E-mail: ahmad.tarefe97@gmail.com

• Received: April 30, 2025 • Revised: July 24, 2025 • Accepted: July 27, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
Graphical abstract
INTRODUCTION
METHODS
RESULTS
DISCUSSION
Supplementary Material
NOTES
REFERENCES

Abstract

Background/Aims
Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are widely prescribed for diabetes and obesity. Recent studies suggest they may negatively affect bowel preparation quality before colonoscopy (CLN), leading to inadequate bowel preparation (IBP) and repeat procedures. We conducted a systematic review and meta-analysis to assess this association.
Methods
PubMed, Embase and Cochrane databases, along with abstracts from Digestive Disease Week 2024 and the American College of Gastroenterology Meeting 2024, were searched. Outcomes included IBP, repeat CLNs, and the mean difference in Boston Bowel Preparation Scale (BBPS) scores between GLP-1 RA users and non-users. Adjusted odds ratios (OR), for age, sex, body mass index, and diabetes, were pooled.
Results
Twelve studies including 123,858 patients (57,699 GLP-1 RA users) were analyzed. GLP-1 RA use was associated with higher IBP risk (OR, 1.55; 95% CI, 1.11–2.16); adjusted analyses confirmed this (OR, 2.35; 95% CI, 2.02–2.74). BBPS scores were lower among GLP-1 RA users (mean difference, –0.68; 95% CI, –0.77 to –0.58). No association with repeat CLNs was observed (OR, 1.5; 95% CI, 0.88–2.56).
Conclusions
GLP-1 RA use is linked to inadequate bowel preparation but not repeat CLNs. Further prospective studies are warranted to further evaluate this finding.
Keywords: Boston bowel preparation scale; Bowel preparation; Colonoscopy; Glucagon-like peptide 1 receptor agonists

Graphical abstract

INTRODUCTION

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are a class of medications that mimic the endogenous gut peptide GLP-1, which exerts physiological effects on multiple organ systems. These effects include enhanced insulin secretion, inhibition of glucagon release, delayed gastric emptying, and appetite suppression.¹^,² The multifaceted mechanisms of action of GLP-1 RAs collectively improve glycemic control and promote weight loss, making them increasingly popular in the treatment of metabolic diseases such as type II diabetes mellitus (DM II) and obesity.¹^-³ The most common side effects experienced by patients treated with GLP-1 RAs are gastrointestinal (GI) in nature, including nausea, vomiting, and diarrhea.¹^,² Constipation is reported in 4% to 12% of patients and occurs more frequently in individuals with obesity, likely due to the use of higher doses.⁴ While the inhibitory effect of GLP-1 RAs on gastric emptying has been well established using a variety of methods, their impact on bowel motility remains less clear. The available literature is limited and conflicting, with studies reporting either prokinetic or inhibitory effects.⁵^-¹⁰

Colonoscopy (CLN) is a widely used tool for the diagnosis and treatment of GI disorders and is generally considered a safe and well-tolerated procedure. With the growing use of GLP-1 RAs and their notable effects on the GI tract, there has been increasing concern regarding their use during the perioperative period. The most recent American Gastroenterological Association (AGA) clinical practice guidelines recommend an individualized approach based on the patient’s risk profile and shared decision-making between treatment teams and the patient.¹¹ While concerns are more pronounced with upper endoscopy due to the potential risk of aspiration of retained gastric contents, GLP-1 RAs may also negatively affect lower endoscopy. Several recent observational studies have examined the impact of GLP-1 RAs on lower GI endoscopy, demonstrating evidence of suboptimal bowel preparation in patients undergoing CLN while on GLP-1 RAs.¹²^-¹⁴ Inadequate bowel preparation can have significant negative consequences, including missed pathological lesions, primarily polyps, and cancelled or aborted procedures, potentially resulting in delayed or repeated examinations.¹³ Further investigation into the effects of GLP-1 RAs on lower endoscopy is warranted to better understand their clinical significance and to inform periendoscopic management. This systematic review and meta-analysis aimed to assess the impact of GLP-1 RA use on bowel preparation during lower GI endoscopy, focusing on clinical outcomes and procedure-related safety.

METHODS

This systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The protocol was registered in the PROSPERO international database (www.crd.york.ac.uk/prospero/) under number CRD420251010303.

Literature search and study selection

A comprehensive literature search was conducted by two independent investigators (A.A., B.A.), with discrepancies resolved by consensus in consultation with a third investigator (P.S.). MEDLINE, Embase, and Cochrane databases, as well as relevant abstracts from Digestive Disease Week 2024 (DDW 2024) and American College of Gastroenterology Meeting 2024 (ACG 2024), were searched from inception to November 2024 to identify studies evaluating the effect of GLP-1 RAs on bowel preparation for CLN. The MeSH terms and keywords used included: “GLP-1 agonists”, “GLP-1”, “GLP-1 RAs”, “glucagon-like peptide 1 agonists”, “semaglutide”, “liraglutide”, “dulaglutide”, “tirzepatide”, “exenatide”, “bowel preparation”, “bowel cleansing”, “colonoscopy preparation”, “lower endoscopy”, and “colonoscopy”. Editorials, notes, congress abstracts, and studies not conducted in humans were excluded. The reference lists of relevant systematic reviews and meta-analyses were manually screened. Only articles written in English were included in this study.

Selection criteria

Inclusion criteria were determined by two authors (A.A. and B.A.) and included observational studies (retrospective or prospective) and randomized controlled trials comparing satisfactory bowel preparation and mean Boston bowel preparation scale (BBPS) scores between GLP-1 RA users and non-users. Satisfactory bowel preparation was defined as a BBPS ≥6. This threshold was based on prior meta-analyses, which demonstrated that a BBPS score >5 is associated with a higher adenoma detection rate, a reduced need for repeat CLNs, and a lower rate of aborted procedures.¹⁵^,¹⁶ No restrictions were applied based on participants’ conditions, characteristics, or treatment indications. Exclusion criteria included experimental studies, animal studies, and review articles. Studies that did not report outcomes of interest were also excluded.

Three authors (A.A., B.A., and L.A.) independently screened titles and abstracts, excluding articles deemed irrelevant. Full texts of potentially eligible studies were reviewed and critically appraised for inclusion. Discrepancies were resolved by consensus, with the assistance of a fourth team member (P.S.) when necessary.

Outcomes

In assessing the impact of GLP-1 RA use on CLN, the primary outcome was the odds of inadequate bowel preparation, defined as a BBPS score <6, among GLP-1 RA users compared to that in non-users. Secondary outcomes included the rate of repeat CLNs and the mean difference in BBPS scores between the two groups.

Data extraction and quality assessment

Data extraction was independently performed by two authors (A.A. and B.A.). The following information was collected: first author’s name, publication title and year, country, participant characteristics and conditions, mean age and sex distribution, type of GLP-1 RA used, treatment and follow-up duration, type of control group, number of participants, diabetes status, indication for CLN, GLP-1 RA use (yes or no), specific GLP-1 RA administered, adequacy of bowel preparation, BBPS score, and whether repeat CLN was reported.

Two independent investigators assessed the risk of bias using the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool.¹⁷ The following domains were evaluated: confounding bias, selection of participants, classification of interventions, deviations from intended interventions, missing data, and measurement of outcomes. The quality assessment results are presented separately in Supplementary Table 1.¹²^-¹⁴^,¹⁸^-²⁶ Any discrepancies in quality assessment were resolved by consensus between the two authors (B.A. and P.S.).

Statistical analysis and data synthesis

Results were expressed as odds ratios (ORs) with 95% confidence intervals (CIs), and p-values were calculated. A p<0.05 was considered statistically significant. Corresponding forest plots were generated to visually represent clinical outcomes. To account for potential confounders, adjusted ORs (adjusted for variables including age, sex, ethnicity, DM II, and obesity) were extracted and pooled. Differences in mean BBPS scores between GLP-1 RA users and non-users were analyzed using effect sizes.

Chi-square and I² tests were used to assess the percentage of variability due to heterogeneity beyond chance across studies. A p>0.10 in the chi-square test and I²<20% were interpreted as indicators of low heterogeneity,²⁷ while values above 75% indicated high heterogeneity. A DerSimonian-Laird random-effects model was applied for the meta-analysis. All statistical analyses were performed using Stata ver. 17.0 (Stata Corp.).

RESULTS

Search results

A systematic review of studies from PubMed, Embase, and Cochrane databases was conducted from inception until November 2024, along with relevant abstracts from DDW 2024 and ACG 2024, to assess the impact of GLP-1 RA use on CLN. The study selection process is illustrated in the schematic diagram in Figure 1. From an initial total of 172 records (after duplicate removal), twelve studies evaluating the impact of GLP-1 RAs on bowel preparation for CLNs met the inclusion criteria and were included in the final analysis.¹²^-¹⁴^,¹⁸^-²⁶ Studies were excluded if they were reviews, meta-analyses, letters, editorials, case reports, case series, or if they evaluated GLP-1 RA users with different baseline characteristics compared to non-users.

Study and patient characteristics

Twelve observational studies assessing the association between GLP-1 RA use and bowel preparation adequacy, mean BBPS, or repeat CLNs were conducted across the United States, China, and the Middle East.¹²^-¹⁴^,¹⁸^-²⁶ A total of 123,858 patients who underwent CLN were included in the analysis, of whom 57,699 were treated with GLP-1 RAs. The primary indications for GLP-1 RA treatment were DM II and obesity. Patient ages ranged from 45 to 75 years in both groups, with the majority being female. Ten studies assessed the association between GLP-1 RA use and bowel preparation adequacy.¹²^-¹⁴^,¹⁸^,²⁰^-²⁵ Four studies evaluated the relationship between GLP-1 RAs and repeat CLNs.¹⁴^,¹⁹^,²⁵^,²⁶ Five studies investigated the mean BBPS difference between GLP-1 RA users and non-users.¹²^,¹⁴^,²²^,²³^,²⁶ Baseline characteristics for each study are summarized in Table 1,¹²^-¹⁴^,¹⁸^-²⁶ and data on the rates of inadequate bowel preparation, repeat CLNs, and mean BBPS differences are presented in Table 2.¹²^-¹⁴^,¹⁸^-²⁶

Meta-analysis of outcomes

1) GLP-1 RA and bowel preparation

Ten studies were included in the final analysis of the association between GLP-1 RA use and bowel preparation quality for CLN.¹²^-¹⁴^,¹⁸^,²⁰^-²⁵ Inadequate bowel preparation was reported in 10.86% of patients (686/6,317) in the GLP-1 RA group, compared with 6.39% (944/14,779) in the non-user group. Overall, GLP-1 RA use was associated with a significantly higher rate of inadequate bowel preparation compared to non-use (OR, 1.55; 95% CI, 1.11–2.16), as shown in Figure 2. This association remained statistically significant in the analysis of adjusted ORs (OR, 2.35; 95% CI, 2.02–2.74), as shown in Figure 3.

2) GLP-1 RA and repeat CLN

Four studies evaluated the association between GLP-1 RA use and repeat CLN.¹⁴^,¹⁹^,²⁵^,²⁶ Repeat procedures occurred in 11.03% of patients (5,712/51,745) in the GLP-1 RA group compared with 9.57% (5,728/59,828) in the non-user group. No statistically significant association was observed between GLP-1 RA use and repeat CLNs (OR, 1.5; 95% CI, 0.88–2.56), as illustrated in Figure 4.

3) GLP-1 RA and mean BBPS difference between groups

Five studies reported data on GLP-1 RA use and mean BBPS scores for CLN.¹²^,¹⁴^,²²^,²³^,²⁶ The mean BBPS scores for the GLP-1 RA group ranged from 4.6 to 9.4 across individual studies, compared to 5.6 to 8.33 in the non-GLP-1 RA group. GLP-1 RA use was significantly associated with a lower mean BBPS score compared to non-users (effect size [ES], –0.68; 95% CI, –0.77 to –0.58), as shown in Figure 5.

DISCUSSION

This systematic review and meta-analysis evaluated the effects of GLP-1 RAs on bowel preparation for CLNs. Our findings indicate that GLP-1 RA use is associated with a statistically significant negative impact on bowel preparation quality, resulting in a higher likelihood of unsatisfactory preparation (i.e., BBPS <6). Additionally, secondary outcomes revealed that GLP-1 RA users had a significantly lower mean BBPS compared to non-users, although no significant difference in the rate of repeat CLNs was observed.

Adequate bowel preparation is essential for high-quality CLN. Inadequate preparation increases the risk of missing important lesions, such as advanced adenomas and serrated polyps. This not only compromises diagnostic accuracy but also contributes to patient dissatisfaction, aborted procedures, repeat CLNs, and wasted healthcare resources.²⁸ For instance, one study reported that among patients with inadequate bowel preparation, adenomas were missed in 47% of cases, particularly when the BBPS score was below 5, compared with 21% in those with excellent preparation.²⁹ Similarly, another study found that initial CLNs with poor preparation had an adenoma detection rate of 25%, which increased to 33.8% upon repeat examination,³⁰ highlighting the risk of missed lesions due to insufficient visualization.

Our findings underscore the association between GLP-1 RA use and inadequate bowel preparation, which may be explained by the drug’s effect on GI motility. GLP-1 slows postprandial GI motility by acting on GLP-1 receptors in myenteric neurons, mediated through nitrergic and cAMP-dependent pathways. This results in delayed gastric emptying and early satiety, which can reduce fiber and fluid intake, thereby contributing to constipation.⁴^,⁹ While many GI side effects of GLP-1 RAs are transient, constipation often persists longer, often lasting up to a month following dose titration, especially in obese patients, who are typically prescribed higher doses.⁴ Management strategies for GLP-1 RA-induced constipation include lifestyle modifications such as increased dietary fiber intake, adequate hydration, regular physical activity, and gradual dose titration.³¹

Nonetheless, GI motility can be affected by multiple factors, including severe diabetes complicated by autonomic neuropathy, gastroparesis, use of anti-motility medications, idiopathic constipation, disability, and severe illness.³² Seven studies included only patients undergoing elective outpatient CLN,¹²^-¹⁴^,¹⁹^,²⁰^,²²^-²⁴ thereby excluding hospitalized patients who may have had undiagnosed ileus related to immobility or inpatient medications. Among the 12 studies, four excluded patients with known GI motility disorders, including autonomic dysfunction¹²^,¹³^,¹⁸^,²³; six excluded those with a history of abdominal surgery or anatomical abnormalities¹²^,¹³^,¹⁸^,¹⁹^,²¹^,²⁴ and four excluded patients using opioids, laxatives, or prokinetic agents.¹²^,¹⁴^,¹⁸^,²⁴ While these exclusions help reduce confounding, they do not eliminate it entirely, and attributing the observed findings solely to GLP-1 RA use remains open to debate. However, four studies adjusted for key variables, such as age, sex, diabetes, and obesity, and still demonstrated a consistent association between GLP-1 RA use and inadequate bowel preparation.¹²^,¹⁸^,²¹^,²⁴ It is also important to acknowledge that the influence of other unrecognized or under-reported GI motility disorders may have been underestimated in the included populations.

GLP-1 RAs vary in their duration of action, with short-acting agents having a half-life of 4 to 6 hours and long-acting agents lasting 5 to 7 days.³³ To date, the medical literature does not clearly demonstrate differential effects of short- versus long-acting GLP-1 RAs on small or large-bowel motility, as most pharmacodynamic differences appear to be confined to gastric emptying.⁵ Short-acting agents tend to delay gastric emptying more consistently, likely due to their frequent dosing, which reduces the likelihood of receptor desensitization.³⁴ In contrast, long-acting agents may lead to receptor downregulation and reduced responsiveness.³⁴ In the studies included in our analysis, several reported baseline demographic data on the number of patients receiving each specific GLP-1 RA. However, none provided outcome data on bowel preparation quality, either overall or stratified by colonic region, in relation to specific agents or dosages. This lack of data limited our ability to assess whether certain agents or doses were more strongly associated with poor bowel preparation. Nonetheless, extrapolating from gastric studies, withholding a single dose may be insufficient to restore baseline bowel motility, as no studies have yet defined the optimal discontinuation interval prior to endoscopic procedures.³⁵

Variability in bowel preparation regimens and fasting protocols may also influence bowel preparation quality independently of GLP-1 RA use.³⁶ Among the included studies, three used high-volume polyethylene glycol (PEG),¹³^,¹⁴^,¹⁸ two used low-volume PEG,¹⁴^,¹⁸ and two employed magnesium- or phosphate-based regimens.¹⁴^,¹⁸ Information on pre-CLN diet protocols was limited: one study recommended a semi-fluid, low-fiber diet for two days¹²; another advised fasting for 4 to 6 hours before CLN¹³; and a third used a clear liquid diet for 24 hours.²⁵ Due to the heterogeneity and limited reporting, pooled analyses assessing the impact of fasting duration or diet type on bowel preparation quality in GLP-1 RA users could not be performed. However, a prospective trial published in Am J Gastroenterol found that magnesium citrate and MiraLAX with Gatorade had superior tolerability and bowel cleansing efficacy compared to GoLYTELY.³⁷ Additionally, a meta-analysis published in Gastroenterology concluded that split-dose regimens are more effective than day-before preparations, with 4-L split-dose PEG showing particularly high efficacy.³⁸

We found that GLP-1 RA use was significantly associated with poorer bowel preparation scores. Although the difference was statistically significant, the effect size was small (ES, –0.68; 95% CI, –0.77 to –0.58), and notably, all four studies that reported BBPS scores had a mean above 6. Specifically, 10.86% of patients in the GLP-1 RA group had inadequate bowel preparation, compared to 6.39% in the non-GLP-1 RA group. This finding highlights that 89.14% of patients on GLP-1 RAs still achieved adequate bowel preparation. However, the included studies did not report postoperative complications, limiting the ability to fully assess the clinical implications of these findings. Additionally, data on adenoma miss rates from repeat CLNs, if performed, would provide further insight into the clinical relevance of this association and could inform practice more meaningfully. Interestingly, the pooled analysis of repeat CLN rates, reported in only four studies, showed no statistically significant difference between GLP-1 RA users and non-users (OR, 1.5; 95% CI, 0.88–2.58). This suggests that continuing GLP-1 RAs prior to CLN may be safe. Nonetheless, further prospective, randomized studies are warranted to explore the reasons for repeat procedures, whether related to GLP-1 RA use or other factors, and to determine if there are differences in adenoma miss rates. Our meta-analysis findings are particularly relevant given the lack of consensus regarding whether GLP-1 RAs should be withheld before endoscopic procedures. While the American Society of Anesthesiologists recommends holding GLP-1 RAs on the day of the procedure for patients on daily dosing and one-week prior for those on weekly dosing, the AGA advises an individualized approach.³⁹

In addition to their glycemic benefits, GLP-1 RAs possess anti-inflammatory properties, reducing biomarkers such as C-reactive protein, tumor necrosis factor-α, and interleukin-6 through immune modulation and direct tissue effects.⁴⁰ These properties may translate into improved surgical outcomes. Studies have associated perioperative GLP-1 RA use with lower rates of postoperative infections, reduced hospital readmissions, and fewer complications, particularly in patients with diabetes or obesity.⁴⁰^-⁴² These findings highlight the potential role of GLP-1 RAs in optimizing surgical recovery by mitigating inflammation-related risks, shortening hospital stays, and improving glycemic control when continued prior to CLN.

Given the importance of optimizing bowel preparation in patients using GLP-1 RAs, a clear clinical need exists for a reliable method to assess bowel cleanliness prior to CLN. Abdominal ultrasound is emerging as a promising noninvasive tool for evaluating fecal burden.⁴³ A recent study successfully used ultrasonography to categorize stool content in patients with functional GI disorders, demonstrating its potential utility.⁴⁴ Additionally, earlier research has suggested that ultrasound may be useful in assessing the efficacy of bowel regimens, as shown in a 2016 prospective study comparing different laxative strategies.⁴⁵ Although the literature on ultrasound for bowel preparation assessment remains limited, its potential application warrants further investigation as a complementary approach for improving CLN outcomes in patients at risk of inadequate preparation.

Our findings should be interpreted with caution, as multiple factors, both reported and under-reported, may contribute to inadequate bowel preparation. Until further studies are conducted that adequately control for key confounding variables, clinical judgment remains essential. For patients taking GLP-1 RAs who are at risk of delayed bowel motility and for whom discontinuation is not feasible due to glycemic control requirements, we recommend practical adjustments. These may include extending the clear liquid diet or fasting period to 24 hours before CLN and ensuring strict adherence to standard bowel preparation protocols. Additionally, providing clear patient instructions regarding expected stool consistency and considering repeat dosing when necessary may help optimize bowel cleanliness and improve procedural success.

The high variability observed across studies, as assessed by the I² test, was statistically significant in all subgroup analyses evaluating bowel preparation. This suggests that differences in factors such as bowel preparation protocols, duration of fasting or clear liquid diet, and GLP-1 RA dosing may have influenced the outcomes. Additionally, the absence of propensity score matching in each study, or for the most relevant confounding variables, may have affected the results. This is particularly important given the potential influence of diabetes severity, related complications, concurrent medication use, and dietary restrictions. Moreover, all included studies were observational in nature, making them susceptible to residual confounding and selection bias.

Despite these limitations, this meta-analysis incorporates the most up-to-date, high-quality studies available in the literature, as well as rigorously peer-reviewed abstracts from national meetings. Together, these sources provide a comprehensive and current summary of the evidence on this topic. As the use of GLP-1 RAs continues to grow, our findings offer valuable insights that can inform clinical decision-making regarding whether to withhold or continue these agents prior to endoscopic procedures, while accounting for multiple patient- and procedure-specific factors.

In conclusion, our study demonstrates a clear association between GLP-1 RA use and inadequate bowel preparation, as well as lower mean BBPS scores. However, no significant association was found with the rate of repeat CLNs. The broader clinical implications of these findings remain uncertain, given the lack of data on related anesthesia complications, such as aspiration risk during repeat procedures, and the potential for missed adenomas. Future research should address these gaps by evaluating clinically significant outcomes and complications, identifying optimal bowel preparation strategies for patients on GLP-1 RAs, and investigating possible dose-dependent effects or differences among specific GLP-1 RA agents with respect to bowel preparation adequacy. When discontinuation of GLP-1 RAs is not feasible due to glycemic control needs, bowel preparation may be optimized through practical strategies. These include providing clear and detailed patient instructions (including repeat dosing guidance if needed), recommending a clear liquid diet or fasting the day before the procedure, evaluating other contributing factors to impaired bowel motility, and considering the use of ultrasound to assess stool burden on the day of CLN.

Supplementary Material

Supplementary Table 1. Quality and risk of bias assessment of included studies using the Revised Cochrane Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool.

ce-2025-137-Supplementary-Table-1.pdf

Supplementary materials related to this article can be found online at https://doi.org/10.5946/ce.2025.137.

Ethical Statements

Not applicable.

Conflicts of Interest

The authors have no potential conflicts of interest.

Funding

None.

Author Contributions

Conceptualization: AA, PS; Data curation: AA, BA, PS, LA; Formal analysis: AA, BA, PS, LA; Investigation: AA, BA, PS, LA; Methodology: AA, PS; Supervision: WKC; Writing–original draft: AA, KB, DQ, NA, GA; Writing–review & editing: all authors.

Fig. 1.

Flow diagram illustrating the article selection process for the systematic review and meta-analysis. GLP-1 RA, glucagon-like peptide-1 receptor agonist; CLN, colonoscopy.

Fig. 2.

Forest plot depicting the meta-analysis of odds ratios (ORs) for inadequate bowel preparation in glucagon-like peptide-1 receptor agonists users vs. non-users. CI, confidence interval.

Fig. 3.

Forest plot depicting the meta-analysis of adjusted odds ratios (ORs) for inadequate bowel preparation in glucagon-like peptide-1 receptor agonists users vs. non-users. ES, effect size; CI, confidence interval.

Fig. 4.

Forest plot showing the meta-analysis of odds ratios (ORs) for repeat colonoscopy in glucagon-like peptide-1 receptor agonist users vs. non-users. CI, confidence interval.

Fig. 5.

Forest plot showing the meta-analysis of mean differences in Boston bowel preparation scale scores between glucagon-like peptide-1 receptor agonist users and non-users. ES, effect size; CI, confidence interval.

Table 1.

The baseline characteristics of each study included in the meta-analysis which evaluates the effect of GLP-1 RAs on bowel preparation for colonoscopy

Study	Year	No. of patients		Age (yr)		Male		Diabetes		Indications for CLN	GLP-1 RA used
Study	Year	GLP-1 RA(+)	GLP-1 RA(–)	GLP-1 RA(+)	GLP-1 RA(–)	GLP-1 RA(+)	GLP-1 RA(–)	GLP-1 RA(+)	GLP-1 RA(–)	Indications for CLN	GLP-1 RA used
Tong et al.¹²	2023	120	120	56.6±9.1	57.1±7.6	75 (62.5)	72 (60.0)	All	All	Screening	Liraglutide, 120 (100.0)
Sharma et al.¹³	2017	126	129	45–75	NR	NR	NR	All	All	Routine screening and/or diagnostic (e.g., constipation, nausea, bloating)	NR
Yao et al.¹⁴	2024	265	181	59.1	59.5	122 (46.0)	83 (45.6)	228 (86.0)	134 (74.0)	Screening, 279 (62.6); surveillance, 167 (37.4)	Semaglutide IM, 129 (48.8); semaglutide PO, 8 (3.1); liraglutide, 30 (11.2); dulaglutide, 92 (34.6); tirzepatide, 1 (0.4); exenatide, 5 (1.9)
Abu-Freha et al.¹⁸	2025	4,876	4,876	60±9.4	60.6±10	2134 (43.8)	2,134 (43.8)	2364 (48.5)	2,364 (48.5)	NR	NR
El Telbany et al.¹⁹	2024	51,281	51,281	NR	NR	NR	NR	36,307 (70.8)	363,075 (70.8)	Screening	NR
Rubin et al.²⁰	2024	49	159	NR	NR	NR	NR	All	All	NR	Semaglutide IM, 19 (9.1); liraglutide, 4 (1.9); dulaglutide, 23 (11.1); tirazepatide, 3 (1.9)
Ghazi et al.²¹	2024	107	107	58.8±10.4	58±8.9	48 (44.9)	44 (49.5)	86 (80.4)	86 (80.4)	Screening, 179 (83.6)	Semaglutide IM, 54 (50.4)
											liraglutide, 13 (12.2)
											dulaglutide, 34 (31.8)
											tirzepatide, 6 (5.6)
Patel et al.²²	2024	249 (37)	424 (63)	61.6	64.4	120 (48.2)	146 (34.4)	NR	NR	NR	Semaglutide IM, 111 (47.4); liraglutide, 33 (13.25); dulaglutide, 90 (36.1); exenatide, 5 (2.0); tirzepatide, 3 (1.2)
Mahmood et al.²³	2024	150	142	NR	NR	NR	NR	112 (74.5)	45 (31.7)	NR	Semaglutide IM, 51 (34); semaglutide PO, 15 (10); liraglutide, 19 (13); dulaglutide, 43 (29); exenatide, 4 (3); tirzepatide, 15 (10); lixisenatide, 3 (2)
Bachu et al.²⁴	2024	277	254	61 (53–69)	62 (53–59)	109 (39.4)	99 (39)		All	Screening, diarrhea, iron deficiency, anemia, other	Semaglutide IM, 122 (44%); semaglutide PO, 14 (5%); liraglutide, 39 (14%); dulaglutide, 88 (32%); exenatide, 3 (1%); tirzepatide, 11 (4%)
Wadehra et al.²⁵	2024	98	NR	65	NR	79 (0.8)	NR	NR	NR	NR	NR
Pierce et al.²⁶	2024	101	99	65.3	63.5	92.9 (92)	84.2 (85)	73.7 (73)	22.8 (23)	NR	NR

Values are presented as number (%), mean±standard deviation, or median (range) unless otherwise indicated.

GLP-1 RA, glucagon-like peptide-1 receptor agonist; CLN, colonoscopy; NR, not reported; IM, intramuscular; PO, per os.

Table 2.

The incidence of inadequate bowl preparation repeat colonoscopy of each study

Study	Year	Satisfactory bowel preparation		BBPS		Repeat colonoscopy
Study	Year	GLP-1 RA(+)	GLP-1 RA(–)	GLP-1 RA(+)	GLP-1 RA(–)	GLP-1 RA(+)	GLP-1 RA(–)
Tong et al.¹²	2023	99 (82.5)	94 (78.3)	6.4±0.8	6.7±0.8	NR	NR
Sharma et al.¹³	2017	116 (92.1)	119 (92.3)	NR	NR	NR	NR
Yao et al.¹⁴	2024	224 (84.5)	169 (93.4)	7.0±2.4	7.5±1.9	50 (18.9)	20 (11.1)
Abu-Freha et al.¹⁸	2025	4,389 (90)	4,679 (96)	NR	NR	NR	NR
El Telbany et al.¹⁹	2024	NR	NR	NR	NR	5,692 (11.1)	5,128 (10)
Rubin et al.²⁰	2024	40 (81.6)	135 (85.5)	NR	NR	NR	NR
Ghazi et al.²¹	2024	98 (91.2)	96 (89.7)	NR	NR	NR	NR
Patel et al.²²	2024	227 (91.2)	411 (96.9)	7.04	7.89	NR	NR
Mahmood et al.²³	2024	118 (78.7)	119 (83.8)	6.94	7.42	NR	NR
Bachu et al.²⁴	2024	233 (84.1)	222 (87.4)	NR	NR	NR	NR
Wadehra et al.²⁵	2024	92 (93)	7,690 (93)	NR	NR	6 (6)	577 (7)
Pierce et al.²⁶	2024	NR	NR	7.09	8.33	16	3

Values are presented as number (%) or mean±standard deviation.

GLP-1 RA, glucagon-like peptide-1 receptor agonist; BBPS, Boston bowel preparation scale; NR, not reported.

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Impact of glucagon-like peptide-1 receptor agonists on colonoscopy outcomes: a systematic review and meta-analysis

Clin Endosc. 2026;59(2):211-222. Published online February 13, 2026

DOI: https://doi.org/10.5946/ce.2025.137

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Impact of glucagon-like peptide-1 receptor agonists on colonoscopy outcomes: a systematic review and meta-analysis

Fig. 1. Flow diagram illustrating the article selection process for the systematic review and meta-analysis. GLP-1 RA, glucagon-like peptide-1 receptor agonist; CLN, colonoscopy.

Fig. 2. Forest plot depicting the meta-analysis of odds ratios (ORs) for inadequate bowel preparation in glucagon-like peptide-1 receptor agonists users vs. non-users. CI, confidence interval.

Fig. 3. Forest plot depicting the meta-analysis of adjusted odds ratios (ORs) for inadequate bowel preparation in glucagon-like peptide-1 receptor agonists users vs. non-users. ES, effect size; CI, confidence interval.

Fig. 4. Forest plot showing the meta-analysis of odds ratios (ORs) for repeat colonoscopy in glucagon-like peptide-1 receptor agonist users vs. non-users. CI, confidence interval.

Fig. 5. Forest plot showing the meta-analysis of mean differences in Boston bowel preparation scale scores between glucagon-like peptide-1 receptor agonist users and non-users. ES, effect size; CI, confidence interval.

Graphical abstract

Fig. 1.

Fig. 2.

Fig. 3.

Fig. 4.

Fig. 5.

Graphical abstract

Impact of glucagon-like peptide-1 receptor agonists on colonoscopy outcomes: a systematic review and meta-analysis

Study	Year	No. of patients		Age (yr)		Male		Diabetes		Indications for CLN	GLP-1 RA used
Study	Year	GLP-1 RA(+)	GLP-1 RA(–)	GLP-1 RA(+)	GLP-1 RA(–)	GLP-1 RA(+)	GLP-1 RA(–)	GLP-1 RA(+)	GLP-1 RA(–)	Indications for CLN	GLP-1 RA used
Tong et al.12	2023	120	120	56.6±9.1	57.1±7.6	75 (62.5)	72 (60.0)	All	All	Screening	Liraglutide, 120 (100.0)
Sharma et al.13	2017	126	129	45–75	NR	NR	NR	All	All	Routine screening and/or diagnostic (e.g., constipation, nausea, bloating)	NR
Yao et al.14	2024	265	181	59.1	59.5	122 (46.0)	83 (45.6)	228 (86.0)	134 (74.0)	Screening, 279 (62.6); surveillance, 167 (37.4)	Semaglutide IM, 129 (48.8); semaglutide PO, 8 (3.1); liraglutide, 30 (11.2); dulaglutide, 92 (34.6); tirzepatide, 1 (0.4); exenatide, 5 (1.9)
Abu-Freha et al.18	2025	4,876	4,876	60±9.4	60.6±10	2134 (43.8)	2,134 (43.8)	2364 (48.5)	2,364 (48.5)	NR	NR
El Telbany et al.19	2024	51,281	51,281	NR	NR	NR	NR	36,307 (70.8)	363,075 (70.8)	Screening	NR
Rubin et al.20	2024	49	159	NR	NR	NR	NR	All	All	NR	Semaglutide IM, 19 (9.1); liraglutide, 4 (1.9); dulaglutide, 23 (11.1); tirazepatide, 3 (1.9)
Ghazi et al.21	2024	107	107	58.8±10.4	58±8.9	48 (44.9)	44 (49.5)	86 (80.4)	86 (80.4)	Screening, 179 (83.6)	Semaglutide IM, 54 (50.4)
											liraglutide, 13 (12.2)
											dulaglutide, 34 (31.8)
											tirzepatide, 6 (5.6)
Patel et al.22	2024	249 (37)	424 (63)	61.6	64.4	120 (48.2)	146 (34.4)	NR	NR	NR	Semaglutide IM, 111 (47.4); liraglutide, 33 (13.25); dulaglutide, 90 (36.1); exenatide, 5 (2.0); tirzepatide, 3 (1.2)
Mahmood et al.23	2024	150	142	NR	NR	NR	NR	112 (74.5)	45 (31.7)	NR	Semaglutide IM, 51 (34); semaglutide PO, 15 (10); liraglutide, 19 (13); dulaglutide, 43 (29); exenatide, 4 (3); tirzepatide, 15 (10); lixisenatide, 3 (2)
Bachu et al.24	2024	277	254	61 (53–69)	62 (53–59)	109 (39.4)	99 (39)		All	Screening, diarrhea, iron deficiency, anemia, other	Semaglutide IM, 122 (44%); semaglutide PO, 14 (5%); liraglutide, 39 (14%); dulaglutide, 88 (32%); exenatide, 3 (1%); tirzepatide, 11 (4%)
Wadehra et al.25	2024	98	NR	65	NR	79 (0.8)	NR	NR	NR	NR	NR
Pierce et al.26	2024	101	99	65.3	63.5	92.9 (92)	84.2 (85)	73.7 (73)	22.8 (23)	NR	NR

Study	Year	Satisfactory bowel preparation		BBPS		Repeat colonoscopy
Study	Year	GLP-1 RA(+)	GLP-1 RA(–)	GLP-1 RA(+)	GLP-1 RA(–)	GLP-1 RA(+)	GLP-1 RA(–)
Tong et al.12	2023	99 (82.5)	94 (78.3)	6.4±0.8	6.7±0.8	NR	NR
Sharma et al.13	2017	116 (92.1)	119 (92.3)	NR	NR	NR	NR
Yao et al.14	2024	224 (84.5)	169 (93.4)	7.0±2.4	7.5±1.9	50 (18.9)	20 (11.1)
Abu-Freha et al.18	2025	4,389 (90)	4,679 (96)	NR	NR	NR	NR
El Telbany et al.19	2024	NR	NR	NR	NR	5,692 (11.1)	5,128 (10)
Rubin et al.20	2024	40 (81.6)	135 (85.5)	NR	NR	NR	NR
Ghazi et al.21	2024	98 (91.2)	96 (89.7)	NR	NR	NR	NR
Patel et al.22	2024	227 (91.2)	411 (96.9)	7.04	7.89	NR	NR
Mahmood et al.23	2024	118 (78.7)	119 (83.8)	6.94	7.42	NR	NR
Bachu et al.24	2024	233 (84.1)	222 (87.4)	NR	NR	NR	NR
Wadehra et al.25	2024	92 (93)	7,690 (93)	NR	NR	6 (6)	577 (7)
Pierce et al.26	2024	NR	NR	7.09	8.33	16	3

Table 1. The baseline characteristics of each study included in the meta-analysis which evaluates the effect of GLP-1 RAs on bowel preparation for colonoscopy

Values are presented as number (%), mean±standard deviation, or median (range) unless otherwise indicated.

GLP-1 RA, glucagon-like peptide-1 receptor agonist; CLN, colonoscopy; NR, not reported; IM, intramuscular; PO, per os.

Table 2. The incidence of inadequate bowl preparation repeat colonoscopy of each study

Values are presented as number (%) or mean±standard deviation.

GLP-1 RA, glucagon-like peptide-1 receptor agonist; BBPS, Boston bowel preparation scale; NR, not reported.