Алгоритм подготовки к эндоскопическим или хирургическим вмешательствам пациентов, получающих инкретиномиметики

Широкое применение агонистов рецепторов ГИП и/или ГПП-1 для лечения сахарного диабета 2-го типа и/или ожирения породило новые вызовы в периоперационном периоде. Данные препараты вызывают замедление опорожнения желудка, из-за чего классические протоколы предоперационного голодания теряют свою эффективность, а риск легочной аспирации остаточным желудочным содержимым существенно возрастает. Подавление межпищеварительного моторного комплекса приводит к тому, что пища и жидкости задерживаются в желудке значительно дольше нормативных значений. Существующие рекомендации по предпроцедурной профилактической отмене этих лекарств сопряжены с риском утраты гликемического и метаболического контроля, поскольку длительный период полувыведения еженедельных форм препаратов требует паузы в лечении продолжительностью свыше 4–5 нед. В статье на основании данных литературы и собственного опыта предлагается новый подход периоперационного ведения без прерывания таргетной терапии инкретиномиметиками, который базируется на предварительной стратификации рисков аспирации. Для пациентов группы низкого риска (находящихся на стабильной «бессимптомной» терапии) обоснованна превентивная комбинированная подготовка: 24-часовая диета из исключительно прозрачных жидкостей в сочетании с профилактическим приемом прокинетиков для принудительного преодоления атонии желудка и стимуляции опорожнения. Для группы высокого риска (наличие диспепсии, старт или эскалация дозы, морбидное ожирение) данная медикаментозно-диетическая подготовка в обязательном порядке дополняется проведением прикроватного ультразвукового исследования желудка (POCUS) непосредственно в день вмешательства. Внедрение предложенной двойной стратегии – медикаментозно-диетической коррекции моторики и ультразвукового контроля – позволяет надежно минимизировать замедление опорожнения желудка и риск бронхолегочной аспирации, не лишая пациентов позитивных эффектов вес-снижающей и кардиометаболической терапии.

1. Lim ECN, Lim CED. Perioperative management of GLP-1 receptor agonists: balancing aspiration risk with therapeutic benefit. SN Compr Clin Med. 2025;7:313. https://doi.org/10.1007/s42399-025-02079-9.

2. Jalleh RJ, Plummer MP, Marathe CS, Umapathysivam MM, Quast DR, Rayner CK et al. Clinical Consequences of Delayed Gastric Emptying With GLP-1 Receptor Agonists and Tirzepatide. J Clin Endocrinol Metab. 2024;110(1):1–15. https://doi.org/10.1210/clinem/dgae719.

3. Bellavance D, Chua S, Mashimo H. Gastrointestinal Motility Effects of GLP-1 Receptor Agonists. Curr Gastroenterol Rep. 2025;27(1):49. https://doi.org/10.1007/s11894-025-00995-3.

4. Shahidifar E, Lesniowska M, Deschenes E, Polcha G, Manzo C, Barreiro T et al. Fasting Duration, Not Timing of Last GLP-1 Dose, Predicts Aspiration Risk Indicators: A Prospective Point-of-Care Gastric Ultrasound Study. Dig Dis Sci. 2025. https://doi.org/10.1007/s10620-025-09570-2.

5. Lahoud C, Kreidieh M, Deeb L. GLP-1 Receptor Agonists in Gastrointestinal Practices: Enhancing Both Procedural and Patient-Related Outcomes. SN Compr Clin Med. 2025;7:181. https://doi.org/10.1007/s42399-025-01961-w.

6. Liu W, Jin Y, Wilde PJ, Hou Y, Wang Y, Han J. Mechanisms, physiology, and recent research progress of gastric emptying. Crit Rev Food Sci Nutr. 2021;61(16):2742–2755. https://doi.org/10.1080/10408398.2020.1784841.

7. Hall JE, Hall ME. Guyton and Hall Textbook of Medical Physiology. 15 th ed. Philadelphia, PA: Elsevier; 2026. 1200 p.

8. Holmes GM, Browning KN, Tong M, Qualls-Creekmore E, Travagli RA. Vagally mediated effects of glucagon-like peptide 1: in vitro and in vivo gastric actions. J Physiol. 2009;587(Pt. 19):4749–4759. https://doi.org/10.1113/jphysiol.2009.175067.

9. Crespo J, Rodríguez-Duque JC, Iruzubieta P, Morel Cerda EC, Velarde-Ruiz Velasco JA. GLP-1 Receptor Agonists and Gastrointestinal Endoscopy: A Narrative Review of Risks, Management Strategies, and the Need for Clinical Consensus. J Clin Med. 2025;14(15):5597. https://doi.org/10.3390/jcm14155597.

10. Yeo YH, Gaddam S, Ng WH, Huang PC; Motility and Metabolic Pharmacoepidemiology Group; Ma KS, Rezaie A. Increased Risk of Aspiration Pneumonia Associated With Endoscopic Procedures Among Patients With Glucagon-like Peptide 1 Receptor Agonist Use. Gastroenterology. 2024;167(2):402–404.e3. https://doi.org/10.1053/j.gastro.2024.03.015.

11. Klein SR, Hobai IA. Semaglutide, delayed gastric emptying, and intraoperative pulmonary aspiration: a case report. Can J Anaesth. 2023;70(8):1394–1396. https://doi.org/10.1007/s12630-023-02440-3.

12. Gulak MA, Murphy P. Regurgitation under anesthesia in a fasted patient prescribed semaglutide for weight loss: a case report. Can J Anaesth. 2023;70(8):1397–1400. https://doi.org/10.1007/s12630-023-02521-3.

13. Mishra S, Persons PA, Bersoux S. Should glucagon-like peptide 1 receptor agonists be withheld during the preoperative period? Cleve Clin J Med. 2025;92(4):209–211. https://doi.org/10.3949/ccjm.92a.24110.

14. Joshi GP, Abdelmalak BB, Weigel WA, Harbell MW, Kuo CI, Soriano SG et al. 2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting Duration-A Modular Update of the 2017 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting. Anesthesiology. 2023;138(2):132–151. https://doi.org/10.1097/ALN.0000000000004381.

15. Oprea AD, Umpierrez GE, Sweitzer BJ, Hepner DL. Perioperative management of patients taking glucagon-like peptide-1 receptor agonists: applying evidence to clinical practice. Anesthesiology. 2024;141(6):1141–1161. https://doi.org/10.1097/ALN.0000000000005204.

16. Joshi GP, Abdelmalak BB, Weigel WA, Soriano SG, Harbell MW, Kuo CI et al. American Society of Anesthesiologists consensus-based guidance on preoperative management of patients (adults and children) on glucagon-like peptide-1 (GLP-1) receptor agonists. Anesthesiology. 2024;141(6):1208–1218. Available at: https://www.asahq.org/about-asa/newsroom/news-releases/2023/06/american-society-of-anesthesiologists-consensus-based-guidance-on-preoperative.

17. Kindel TL, Wang AY, Wadhwa A, Schulman AR, Sharaiha RZ, Kroh M et al. Multisociety Clinical Practice Guidance for the Safe Use of Glucagon-like Peptide-1 Receptor Agonists in the Perioperative Period. Clin Gastroenterol Hepatol. 2025;23(12):2083–2085. doi:10.1016/j.cgh.2024.10.003.

18. Avraham SA, Hossein J, Somri F, Hawash N, Hochman O. Pulmonary aspiration of gastric contents in two patients taking semaglutide for weight loss. Anaesth Rep. 2024;12(1):e12278. https://doi.org/10.1002/anr3.12278.

19. Давыдова НС, Лещенко РЕ, Заболотских ИБ, Кузовлев АН, Куликов АВ, Лебединский КМ, Собетова ГВ. Процедурная седация и анальгоседация взрослых пациентов при диагностической эзофагогастродуоденоскопии и колоноскопии. Методические рекомендации Общероссийской общественной организации «Федерация анестезиологов и реаниматологов». Вестник интенсивной терапии имени А.И. Салтанова. 2026;(1):20–43. https://doi.org/10.21320/1818-474X-2026-1-20-43.

20. Oprea AD, Ostapenko LJ, Sweitzer B, Selzer A, Irizarry-Alvarado JM, Hurtado Andrade MD et al. Perioperative management of patients taking glucagon-like peptide 1 receptor agonists: Society for Perioperative Assessment and Quality Improvement (SPAQI) multidisciplinary consensus statement. Br J Anaesth. 2025;135(1):48–78. https://doi.org/10.1016/j.bja.2025.04.001.

21. Hashash JG, Thompson CC, Wang AY. AGA Rapid Clinical Practice Update on the Management of Patients Taking GLP-1 Receptor Agonists Prior to Endoscopy: Communication. Clin Gastroenterol Hepatol. 2024;22(4):705–707. https://doi.org/10.1016/j.cgh.2023.11.002.

22. Hocking SL, Scott DA, Remedios ML, Horowitz M, Story DA, Greenfield JR, et al. Clinical practice recommendations regarding patients taking GLP-1 receptor agonists and dual GLP-1/GIP receptor co-agonists prior to anaesthesia or sedation for surgical and endoscopic procedures. ANZCA Consensus Statement. 2025. Available at: https://www.anzca.edu.au/resources/professional-documents/endorsed-guidelines/periprocedural-glp-1-use-consensus-clinical-guide.pdf.

23. El-Boghdadly K, Dhesi J, Fabb P, Levy N, Lobo DN, McKechnie A et al. Elective peri-operative management of adults taking glucagon-like peptide-1 receptor agonists, glucose-dependent insulinotropic peptide agonists and sodiumglucose cotransporter-2 inhibitors: a multidisciplinary consensus statement: A consensus statement from the Association of Anaesthetists, Association of British Clinical Diabetologists, British Obesity and Metabolic Surgery Society, Centre for Perioperative Care, Joint British Diabetes Societies for Inpatient Care, Royal College of Anaesthetists, Society for Obesity and Bariatric Anaesthesia and UK Clinical Pharmacy Association. Anaesthesia. 2025;80(4):412–424. https://doi.org/10.1111/anae.16541.

24. Jalleh RJ, Rayner CK, Hausken T, Jones KL, Camilleri M, Horowitz M. Gastrointestinal effects of GLP-1 receptor agonists: mechanisms, management, and future directions. Lancet Gastroenterol Hepatol. 2024;9(10):957–964. https://doi.org/10.1016/s2468-1253(24)00188-2.

25. Салухов ВВ, Галстян ГР, Халимов ЮШ, Бакулин ИГ, Черкашин ДВ, Шадричев ФЕ, Сухоцкая НА. Практическое применение семаглутида: от доказательных исследований к экспертным решениям. Медицинский совет. 2025;19(6):14–29. https://doi.org/10.21518/ms2025-185.

26. Maselli DB, Lee D, Bi D, Jirapinyo P, Thompson CC, Donnangelo LL, McGowan CE. Safe Continuation of Glucagon-like Peptide 1 Receptor Agonists at Endoscopy: A Case Series of 57 Adults Undergoing Endoscopic Sleeve Gastroplasty. Obes Surg. 2024;34(7):2369–2374. https://doi.org/10.1007/s11695-024-07278-2.

27. Ahmad AI, Garg S, Jacobs J, Ansari Z, Al-Din TJ, Almomani A et al. Holding vs Continuing GLP-1/GIP Agonists Before Upper Endoscopy: The OCULUS Randomized Clinical Trial. JAMA Intern Med. 2026;186(5):578–584. https://doi.org/10.1001/jamainternmed.2026.0027.

28. Vlaeminck N, Van de Putte P, Dekeyser M, Baert N, Wallin A, Vernieuwe L et al. Gastric ultrasound in patients receiving semaglutide: a prospective multicentre matched cohort study. Anaesthesia. 2026. https://doi.org/10.1111/anae.70129.

29. Ghazanfar H, Javed N, Qasim A, Sosa F, Altaf F, Khan S et al. Is it necessary to stop glucagon-like peptide-1 receptor agonists prior to endoscopic procedure? A retrospective study. World J Gastroenterol. 2024;30(26):3221–3228. https://doi.org/10.3748/wjg.v30.i26.3221.

30. Elkin J, Rele S, Sumithran P, Hii M, Thuraisingam S, Spelman T et al. Association between glucagon-like peptide-1 receptor agonist use and peri-operative pulmonary aspiration: a systematic review and meta-analysis. Anaesthesia. 2025;80(7):846–858. https://doi.org/10.1111/anae.16601.

31. Tarar ZI, Farooq U, Chaudhry A, Gandhi M, El Alayli A, Ayoub M et al. Evidence Report on the Safety of Gastrointestinal Endoscopy in Patients on Glucagon-like Peptide-1 Receptor Agonists: A Systematic Review and Meta-Analysis. Diagnostics. 2025;15(6):770. https://doi.org/10.3390/diagnostics15060770.

32. Robalino Gonzaga E, Farooq A, Mohammed A, Chandan S, Fawwaz B, Singh G et al. Real-World Impact of GLP-1 Receptor Agonists on Endoscopic Patient Outcomes in an Ambulatory Setting: A Retrospective Study at a Large Tertiary Center. J Clin Med. 2024;13(18):5403. https://doi.org/10.3390/jcm13185403.

33. Firkins SA, Yates J, Shukla N, Garg R, Vargo JJ, Lembo A; Cleveland Clinic Obesity Medicine and Bariatric Endoscopy Working Group. Clinical Outcomes and Safety of Upper Endoscopy While on Glucagon-Like Peptide-1 Receptor Agonists. Clin Gastroenterol Hepatol. 2025;23(5):872–873.e3. https://doi.org/10.1016/j.cgh.2024.03.013.

34. Baldawi M, Ghaleb N, McKelvey G, Ismaeil YM, Saasouh W. Preoperative ultrasound assessment of gastric content in patients with diabetes: A meta-analysis based on a systematic review of the current literature. J Clin Anesth. 2024;93:111365. https://doi.org/10.1016/j.jclinane.2023.111365.

35. Garza K, Aminpour E, Shah J, Mehta B, Early D, Gyawali CP, Kushnir V. Glucagon-Like Peptide-1 Receptor Agonists Increase Solid Gastric Residue Rates on Upper Endoscopy Especially in Patients With Complicated Diabetes: A Case-Control Study. Am J Gastroenterol. 2024;119(6):1081–1088. https://doi.org/10.14309/ajg.0000000000002777.

36. Sen S, Potnuru PP, Hernandez N, Goehl C, Praestholm C, Sridhar S, Nwokolo OO. Glucagon-Like Peptide-1 Receptor Agonist Use and Residual Gastric Content Before Anesthesia. JAMA Surg. 2024;159(6):660–667. https://doi.org/10.1001/jamasurg.2024.0111.

37. Silveira SQ, da Silva LM, de Campos Vieira Abib A, de Moura DTH, de Moura EGH, Santos LB et al. Relationship between perioperative semaglutide use and residual gastric content: A retrospective analysis of patients undergoing elective upper endoscopy. J Clin Anesth. 2023;87:111091. https://doi.org/10.1016/j.jclinane.2023.111091.

38. Shahidifar E, Lesniowska M, Deschenes E, Polcha G, Manzo C, Barreiro T et al. Fasting Duration, Not Timing of Last GLP-1 Dose, Predicts Aspiration Risk Indicators: A Prospective Point-of-Care Gastric Ultrasound Study. Dig Dis Sci. 2025. https://doi.org/10.1007/s10620-025-09570-2.

39. Perlas A, Chan VW, Lupu CM, Mitsakakis N, Hanbidge A. Ultrasound assessment of gastric content and volume. Anesthesiology. 2009;111:82–89. https://doi.org/10.1097/aln.0b013e3181a97252.

40. Muranaka MO, Nguyen TH, Wang AT, Cordero J, Yang SJ, Felix J et al. Role of Gastric Point-of-Care Ultrasound in Perioperative Management of Semaglutide. Cureus. 2025;17(6):e85791. https://doi.org/10.7759/cureus.85791.

41. Perlas A, Arzola C, Van de Putte P. Point-of-care gastric ultrasound and aspiration risk assessment: a narrative review. Can J Anaesth. 2018;65(4):437–448. https://doi.org/10.1007/s12630-017-1031-9.

42. Meier JJ, Kemmeries G, Holst JJ, Nauck MA. Erythromycin antagonizes the deceleration of gastric emptying by glucagon-like peptide 1 and unmasks its insulinotropic effect in healthy subjects. Diabetes. 2005;54(7):2212–2218. https://doi.org/10.2337/diabetes.54.7.2212.

43. Shakhatreh M, Jehangir A, Malik Z, Parkman HP. Metoclopramide for the treatment of diabetic gastroparesis. Expert Rev Gastroenterol Hepatol. 2019;13(8):711–721. https://doi.org/10.1080/17474124.2019.1645594.

44. Шептулин АА, Трухманов АС, Сторонова ОА, Румянцева ДЕ. Cогласительное совещание Европейского общества нейрогастроэнтерологии и моторики по гастропарезу (2020): какие вопросы остаются нерешенными? Российский журнал гастроэнтерологии, гепатологии, колопроктологии. 2022;32(4):89–94. https://doi.org/10.22416/1382-4376-2022-32-4-89-94.