Latest News

The use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) has increased over the past several years and has become a cornerstone in both diabetes and weight loss management, particularly because of its unique combination of glucose control, weight reduction potential, and cardiac and metabolic benefits. However, increased use of these agents presents a dilemma in gastrointestinal endoscopy as it pertains to their safety and management during the periprocedural period.

This review explores management of GLP-1 RAs in the periprocedural setting for endoscopic procedures based on current evidence and guidelines, highlighting gaps and future directions.

 

Pharmacology and Mechanisms of Action

GLP-1 RAs have several mechanisms of action that make them relevant in gastrointestinal endoscopy. These medications modulate glucose control via enhancement of glucose-dependent insulin secretion and reduction of postprandial glucagon, which promotes satiety and delays gastric emptying. This delay in gastric emptying mediated by vagal pathways has been postulated to increase gastric residuals, posing a risk for aspiration during anesthesia.¹

It is important to also consider the pharmacokinetics of GLP-1 RAs, as some have shorter half-lives on the order of several hours, like exenatide, while others, like semaglutide, are dosed weekly. Additionally, common side effects of GLP-1 RAs include nausea, vomiting, bloating, and early satiety, which pose challenges for patients undergoing endoscopic procedures. 

 

Current Guidelines

Various societies have published guidelines on the periprocedural use of GLP-1 RAs. The American Society of Anesthesiologist (ASA) in 2023 presented early recommendations to hold GLP-1 RAs either day of procedure or week prior depending on pharmacokinetics, because of the risk of delayed gastric emptying and increased potential for aspiration.² Soon thereafter, a multi-gastroenterology society guideline was released stating more data is needed to decide if GLP-1 RAs need to be held prior to endoscopic procedures.³

In early 2024, the American Gastroenterological Association (AGA) published a rapid clinical update that advocated for a more individualized approach, particularly in light of limited overall data for GLP-1 RAs and endoscopic procedures.⁴ In asymptomatic patients who follow typical fasting protocols for procedures, it is generally safe to proceed with endoscopy without holding GLP-1 RAs. In symptomatic patients (nausea, abdominal distension, etc), the AGA advises additional precautions, including performing transabdominal ultrasound if feasible to assess retained gastric contents. The AGA also suggests placing a patient on a clear liquid diet the day prior to the procedure — rather than holding GLP-1 RAs — as another reasonable strategy.

The guidelines continue to evolve with newer multi-society guidelines establishing best practices. While initially in 2023 the ASA did recommend holding these medications prior to endoscopy, the initial guidance was based on expert opinion with limited evidence. Newer multi-society guidance published jointly by the ASA along with various gastroenterology societies, including the AGA in December 2024, takes a more nuanced approach.⁵

The newer guidelines include two main recommendations:

1. Periprocedural management of GLP-1 RAs should be a joint decision among the procedural, anesthesia, and prescribing team balancing metabolic needs vs patient risks.

• In a low-risk patient, one that is asymptomatic and on standard dosing, among other factors, the guidance states that GLP-1 RAs can be continued.
• In higher-risk patients, the original guidance of holding a day or a week prior to endoscopic procedures should be followed.

2. Periprocedural management of GLP-1 RAs should attempt to minimize the aspiration risks loosely associated with delayed gastric emptying.

• Consider a 24-hour clear liquid diet a day prior to the procedure and transabdominal ultrasound to check gastric contents.
• It is acknowledged that this guidance is based on limited evidence and will be evolving as new medications and data are released.

Recent Clinical Studies

Although there is very little data to guide clinicians, several recent studies have been published that can direct clinical decision-making as guidelines continue to be refined and updated.

A multicenter trial of approximately 800 patients undergoing upper endoscopy found a significant difference in rates of retained gastric contents between those that underwent endoscopy who did and did not follow the ASA guidance on periprocedural management of GLP-1 RAs (12.7% vs 4.4%; P < .0001). However, there were no significant differences in rates of aborted procedures or unplanned intubations.

Furthermore, a multivariable analysis was performed controlling for GLP-1 RA type and other factors, which found the likelihood of gastric retention increased by 36% for every 1% increase in hemoglobin A1c. This study suggests that a more individualized approach to holding GLP-1 RA would be applicable rather than a universal periprocedural hold.⁶

More recently, a single-center study of nearly 600 patients undergoing upper endoscopy showed that while there were slightly increased rates of retained gastric contents (OR 3.80; P = .003) and aborted procedures (1.3% vs 0%; P = .02), the rates of adverse anesthesia events (hypoxia, etc) were similar between the groups and no cases of pulmonary aspiration were noted.7

One single-center study of 57 patients evaluated the safety of GLP-1 RAs in those undergoing endoscopic sleeve gastrectomy. GLP-1 RAs were continued on all patients, but all adhered to a liquid only diet for at least 24 hours prior to the procedure. There were no instances of retained gastric solids, aspiration, or hypoxia. This study suggests that with a 24-hour clear liquid diet and routine NPO recommendations prior to endoscopy, it would be safe to continue GLP-1 RAs. This study provides rationale for the AGA recommendation for a clear liquid diet 24 hours prior to endoscopic procedures for those on GLP-1 RAs.⁸

A study looking at those who underwent emergency surgery and endoscopy with claims data of use of GLP-1 RAs found an overall incidence of postoperative respiratory complications of 3.5% for those with GLP-1 RAs fill history vs 4.0% for those without (P = .12). Approximately 800 of the 24,000 patients identified had undergone endoscopic procedures for GI bleeding or food impaction. The study overall showed that preoperative use of GLP-1 RAs in patients undergoing surgery or endoscopy, evaluated as a combined group, was not associated with an increased risk of pulmonary complications.⁹

Lastly, a systematic review and meta-analysis that included 15 studies that quantified gastric emptying using various methods, including gastric emptying scintigraphy and acetaminophen absorption test, found that there was a quantifiable delay in gastric emptying of about 36 minutes, compared to placebo (P < .01), in patients using GLP-1 RAs. However, compared to standard periprocedural fasting, this delay is clinically insignificant and standard fasting protocols would still be appropriate for patients on GLP-1 RAs.¹⁰

These studies taken together suggest that while GLP-1 RAs can mildly increase the likelihood of retained gastric contents, there is no statistically significant increase in the risk of aspiration or other anesthesia complications. Furthermore, while decreased gastric emptying is a known effect of GLP-1 RAs, this effect may not be clinically significant in the context of standard periprocedural fasting protocols particularly when combined with a 24-hour clear liquid diet. These findings support at a minimum a more patient-specific strategy for periprocedural management of GLP-1 RAs.

 

Clinical Implications

These most recent studies, as well as prior studies and guidelines by various societies lead to a dilemma among endoscopists on proper patient counseling on GLP-1 RAs use before endoscopic procedures. Clinicians must balance the metabolic benefits of GLP-1 RAs with potential endoscopic complications and risks.

Holding therapy theoretically decreases aspiration risk and pulmonary complications, though evidence remains low to support this. Holding medication, however, affects glycemic control leading to potential rebound hyperglycemia which may impact and delay plans for endoscopy. With growing indications for the use of GLP-1 RAs, a more tailored patient-centered treatment plan may be required, especially with consideration of procedure indication and comorbidities.

Currently, practice patterns at different institutions vary widely, making standardization much more difficult. Some centers have opted to follow ASA guidelines of holding these medications up to 1 week prior to procedures, while others have continued therapy with no pre-procedural adjustments. This leaves endoscopists to deal with the downstream effects of inconvenience to patients, care delays, and financial considerations if procedures are postponed related to GLP-1 RAs use.

 

Future Directions

Future studies are needed to make further evidence-based recommendations. Studies should focus on stratifying risks and recommendations based on procedure type (EGD, colonoscopy, etc). More widespread implementation of gastric ultrasound can assist in real-time decision-making, albeit this would require expertise and dedicated time within the pre-procedural workflow. Randomized controlled trials comparing outcomes of patients who continue GLP-1 RAs vs those who discontinue stratified by baseline risk will be instrumental for making concrete guidelines that provide clarity on periprocedural management of GLP-1 RAs.

Conclusion

The periprocedural management of GLP-1 RAs remains a controversial topic that presents unique challenges in endoscopy. Several guidelines have been released by various stakeholders including anesthesiologists, gastroenterologists, and other prescribing providers. Clinical data remains limited with no robust evidence available to suggest that gastric emptying delays caused by GLP-1 RAs prior to endoscopic procedures significantly increases risk of aspiration, pulmonary complications, or other comorbidities. Evolving multi-society guidelines will be important to establish more consistent practices with reassessment of the data as new studies emerge. A multidisciplinary, individualized patient approach may be the best strategy for managing GLP-1 RAs for patients undergoing endoscopic procedures.

Dr. Sekar and Dr. Asamoah are based in the department of gastroenterology at MedStar Georgetown University Hospital, Washington, D.C. Dr. Sekar reports no conflicts of interest in regard to this article. Dr. Asamoah serves on the Johnson & Johnson advisory board for inflammatory bowel disease–related therapies.

References

1. Halim MA et al. Glucagon-Like Peptide-1 Inhibits Prandial Gastrointestinal Motility Through Myenteric Neuronal Mechanisms in Humans. J Clin Endocrinol Metab. 2018 Feb. doi: 10.1210/jc.2017-02006.

2. American Society of Anesthesiologists. American Society of Anesthesiologists releases consensus-based guidance on preoperative use of GLP-1 receptor agonists. 2023 Jun 20. www.asahq.org/about-asa/newsroom/news-releases/2023/06/american-society-of-anesthesiologists-consensus-based-guidance-on-preoperative

3. American Gastroenterological Association. GI multi-society statement regarding GLP-1 agonists and endoscopy. 2023 Jul 25. gastro.org/news/gi-multi-society-statement-regarding-glp-1-agonists-and-endoscopy/.

4. Hashash JG et al. AGA Rapid Clinical Practice Update on the Management of Patients Taking GLP-1 Receptor Agonists Prior to Endoscopy: Communication. Clin Gastroenterol Hepatol. 2024 Apr. doi: 10.1016/j.cgh.2023.11.002.

5. Kindel TL et al; American Gastroenterological Association; American Society for Metabolic and Bariatric Surgery; American Society of Anesthesiologists; International Society of Perioperative Care of Patients with Obesity; Society of American Gastrointestinal and Endoscopic Surgeons. Multi-society Clinical Practice Guidance for the Safe Use of Glucagon-like Peptide-1 Receptor Agonists in the Perioperative Period. Clin Gastroenterol Hepatol. 2024 Oct. doi: 10.1016/j.cgh.2024.10.003.

6. Phan J et al. Glucagon-Like Peptide Receptor Agonists Use Before Endoscopy Is Associated With Low Retained Gastric Contents: A Multicenter Cross-Sectional Analysis. Am J Gastroenterol. 2025 Mar. doi: 10.14309/ajg.0000000000002969.

7. Panchal S et al. Endoscopy and Anesthesia Outcomes Associated With Glucagon-like Peptide-1 Receptor Agonist use in Patients Undergoing Outpatient Upper Endoscopy. Gastrointest Endosc. 2025 Aug. doi:10.1016/j.gie.2025.01.004.

8. Maselli DB et al. Safe Continuation of glucagon-like Peptide 1 Receptor Agonists at Endoscopy: A Case Series of 57 Adults Undergoing Endoscopic Sleeve Gastroplasty. Obes Surg. 2024 Jul. doi: 10.1007/s11695-024-07278-2.

9. Dixit AA et al. Preoperative GLP-1 Receptor Agonist Use and Risk of Postoperative Respiratory Complications. JAMA. 2024 Apr. doi: 10.1001/jama.2024.5003.

10. Hiramoto B et al. Quantified Metrics of Gastric Emptying Delay by Glucagon-Like Peptide-1 Agonists: A systematic review and meta-analysis with insights for periprocedural management. Am J Gastroenterol. 2024 Jun. doi: 10.14309/ajg.0000000000002820.

The use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) has increased over the past several years and has become a cornerstone in both diabetes and weight loss management, particularly because of its unique combination of glucose control, weight reduction potential, and cardiac and metabolic benefits. However, increased use of these agents presents a dilemma in gastrointestinal endoscopy as it pertains to their safety and management during the periprocedural period.

This review explores management of GLP-1 RAs in the periprocedural setting for endoscopic procedures based on current evidence and guidelines, highlighting gaps and future directions.

 

Pharmacology and Mechanisms of Action

GLP-1 RAs have several mechanisms of action that make them relevant in gastrointestinal endoscopy. These medications modulate glucose control via enhancement of glucose-dependent insulin secretion and reduction of postprandial glucagon, which promotes satiety and delays gastric emptying. This delay in gastric emptying mediated by vagal pathways has been postulated to increase gastric residuals, posing a risk for aspiration during anesthesia.¹

It is important to also consider the pharmacokinetics of GLP-1 RAs, as some have shorter half-lives on the order of several hours, like exenatide, while others, like semaglutide, are dosed weekly. Additionally, common side effects of GLP-1 RAs include nausea, vomiting, bloating, and early satiety, which pose challenges for patients undergoing endoscopic procedures. 

 

Current Guidelines

Various societies have published guidelines on the periprocedural use of GLP-1 RAs. The American Society of Anesthesiologist (ASA) in 2023 presented early recommendations to hold GLP-1 RAs either day of procedure or week prior depending on pharmacokinetics, because of the risk of delayed gastric emptying and increased potential for aspiration.² Soon thereafter, a multi-gastroenterology society guideline was released stating more data is needed to decide if GLP-1 RAs need to be held prior to endoscopic procedures.³

In early 2024, the American Gastroenterological Association (AGA) published a rapid clinical update that advocated for a more individualized approach, particularly in light of limited overall data for GLP-1 RAs and endoscopic procedures.⁴ In asymptomatic patients who follow typical fasting protocols for procedures, it is generally safe to proceed with endoscopy without holding GLP-1 RAs. In symptomatic patients (nausea, abdominal distension, etc), the AGA advises additional precautions, including performing transabdominal ultrasound if feasible to assess retained gastric contents. The AGA also suggests placing a patient on a clear liquid diet the day prior to the procedure — rather than holding GLP-1 RAs — as another reasonable strategy.

The guidelines continue to evolve with newer multi-society guidelines establishing best practices. While initially in 2023 the ASA did recommend holding these medications prior to endoscopy, the initial guidance was based on expert opinion with limited evidence. Newer multi-society guidance published jointly by the ASA along with various gastroenterology societies, including the AGA in December 2024, takes a more nuanced approach.⁵

The newer guidelines include two main recommendations:

1. Periprocedural management of GLP-1 RAs should be a joint decision among the procedural, anesthesia, and prescribing team balancing metabolic needs vs patient risks.

• In a low-risk patient, one that is asymptomatic and on standard dosing, among other factors, the guidance states that GLP-1 RAs can be continued.
• In higher-risk patients, the original guidance of holding a day or a week prior to endoscopic procedures should be followed.

2. Periprocedural management of GLP-1 RAs should attempt to minimize the aspiration risks loosely associated with delayed gastric emptying.

• Consider a 24-hour clear liquid diet a day prior to the procedure and transabdominal ultrasound to check gastric contents.
• It is acknowledged that this guidance is based on limited evidence and will be evolving as new medications and data are released.

Recent Clinical Studies

Although there is very little data to guide clinicians, several recent studies have been published that can direct clinical decision-making as guidelines continue to be refined and updated.

A multicenter trial of approximately 800 patients undergoing upper endoscopy found a significant difference in rates of retained gastric contents between those that underwent endoscopy who did and did not follow the ASA guidance on periprocedural management of GLP-1 RAs (12.7% vs 4.4%; P < .0001). However, there were no significant differences in rates of aborted procedures or unplanned intubations.

Furthermore, a multivariable analysis was performed controlling for GLP-1 RA type and other factors, which found the likelihood of gastric retention increased by 36% for every 1% increase in hemoglobin A1c. This study suggests that a more individualized approach to holding GLP-1 RA would be applicable rather than a universal periprocedural hold.⁶

More recently, a single-center study of nearly 600 patients undergoing upper endoscopy showed that while there were slightly increased rates of retained gastric contents (OR 3.80; P = .003) and aborted procedures (1.3% vs 0%; P = .02), the rates of adverse anesthesia events (hypoxia, etc) were similar between the groups and no cases of pulmonary aspiration were noted.7

One single-center study of 57 patients evaluated the safety of GLP-1 RAs in those undergoing endoscopic sleeve gastrectomy. GLP-1 RAs were continued on all patients, but all adhered to a liquid only diet for at least 24 hours prior to the procedure. There were no instances of retained gastric solids, aspiration, or hypoxia. This study suggests that with a 24-hour clear liquid diet and routine NPO recommendations prior to endoscopy, it would be safe to continue GLP-1 RAs. This study provides rationale for the AGA recommendation for a clear liquid diet 24 hours prior to endoscopic procedures for those on GLP-1 RAs.⁸

A study looking at those who underwent emergency surgery and endoscopy with claims data of use of GLP-1 RAs found an overall incidence of postoperative respiratory complications of 3.5% for those with GLP-1 RAs fill history vs 4.0% for those without (P = .12). Approximately 800 of the 24,000 patients identified had undergone endoscopic procedures for GI bleeding or food impaction. The study overall showed that preoperative use of GLP-1 RAs in patients undergoing surgery or endoscopy, evaluated as a combined group, was not associated with an increased risk of pulmonary complications.⁹

Lastly, a systematic review and meta-analysis that included 15 studies that quantified gastric emptying using various methods, including gastric emptying scintigraphy and acetaminophen absorption test, found that there was a quantifiable delay in gastric emptying of about 36 minutes, compared to placebo (P < .01), in patients using GLP-1 RAs. However, compared to standard periprocedural fasting, this delay is clinically insignificant and standard fasting protocols would still be appropriate for patients on GLP-1 RAs.¹⁰

These studies taken together suggest that while GLP-1 RAs can mildly increase the likelihood of retained gastric contents, there is no statistically significant increase in the risk of aspiration or other anesthesia complications. Furthermore, while decreased gastric emptying is a known effect of GLP-1 RAs, this effect may not be clinically significant in the context of standard periprocedural fasting protocols particularly when combined with a 24-hour clear liquid diet. These findings support at a minimum a more patient-specific strategy for periprocedural management of GLP-1 RAs.

 

Clinical Implications

These most recent studies, as well as prior studies and guidelines by various societies lead to a dilemma among endoscopists on proper patient counseling on GLP-1 RAs use before endoscopic procedures. Clinicians must balance the metabolic benefits of GLP-1 RAs with potential endoscopic complications and risks.

Holding therapy theoretically decreases aspiration risk and pulmonary complications, though evidence remains low to support this. Holding medication, however, affects glycemic control leading to potential rebound hyperglycemia which may impact and delay plans for endoscopy. With growing indications for the use of GLP-1 RAs, a more tailored patient-centered treatment plan may be required, especially with consideration of procedure indication and comorbidities.

Currently, practice patterns at different institutions vary widely, making standardization much more difficult. Some centers have opted to follow ASA guidelines of holding these medications up to 1 week prior to procedures, while others have continued therapy with no pre-procedural adjustments. This leaves endoscopists to deal with the downstream effects of inconvenience to patients, care delays, and financial considerations if procedures are postponed related to GLP-1 RAs use.

 

Future Directions

Future studies are needed to make further evidence-based recommendations. Studies should focus on stratifying risks and recommendations based on procedure type (EGD, colonoscopy, etc). More widespread implementation of gastric ultrasound can assist in real-time decision-making, albeit this would require expertise and dedicated time within the pre-procedural workflow. Randomized controlled trials comparing outcomes of patients who continue GLP-1 RAs vs those who discontinue stratified by baseline risk will be instrumental for making concrete guidelines that provide clarity on periprocedural management of GLP-1 RAs.

Conclusion

The periprocedural management of GLP-1 RAs remains a controversial topic that presents unique challenges in endoscopy. Several guidelines have been released by various stakeholders including anesthesiologists, gastroenterologists, and other prescribing providers. Clinical data remains limited with no robust evidence available to suggest that gastric emptying delays caused by GLP-1 RAs prior to endoscopic procedures significantly increases risk of aspiration, pulmonary complications, or other comorbidities. Evolving multi-society guidelines will be important to establish more consistent practices with reassessment of the data as new studies emerge. A multidisciplinary, individualized patient approach may be the best strategy for managing GLP-1 RAs for patients undergoing endoscopic procedures.

Dr. Sekar and Dr. Asamoah are based in the department of gastroenterology at MedStar Georgetown University Hospital, Washington, D.C. Dr. Sekar reports no conflicts of interest in regard to this article. Dr. Asamoah serves on the Johnson & Johnson advisory board for inflammatory bowel disease–related therapies.

References

1. Halim MA et al. Glucagon-Like Peptide-1 Inhibits Prandial Gastrointestinal Motility Through Myenteric Neuronal Mechanisms in Humans. J Clin Endocrinol Metab. 2018 Feb. doi: 10.1210/jc.2017-02006.

2. American Society of Anesthesiologists. American Society of Anesthesiologists releases consensus-based guidance on preoperative use of GLP-1 receptor agonists. 2023 Jun 20. www.asahq.org/about-asa/newsroom/news-releases/2023/06/american-society-of-anesthesiologists-consensus-based-guidance-on-preoperative

3. American Gastroenterological Association. GI multi-society statement regarding GLP-1 agonists and endoscopy. 2023 Jul 25. gastro.org/news/gi-multi-society-statement-regarding-glp-1-agonists-and-endoscopy/.

4. Hashash JG et al. AGA Rapid Clinical Practice Update on the Management of Patients Taking GLP-1 Receptor Agonists Prior to Endoscopy: Communication. Clin Gastroenterol Hepatol. 2024 Apr. doi: 10.1016/j.cgh.2023.11.002.

5. Kindel TL et al; American Gastroenterological Association; American Society for Metabolic and Bariatric Surgery; American Society of Anesthesiologists; International Society of Perioperative Care of Patients with Obesity; Society of American Gastrointestinal and Endoscopic Surgeons. Multi-society Clinical Practice Guidance for the Safe Use of Glucagon-like Peptide-1 Receptor Agonists in the Perioperative Period. Clin Gastroenterol Hepatol. 2024 Oct. doi: 10.1016/j.cgh.2024.10.003.

6. Phan J et al. Glucagon-Like Peptide Receptor Agonists Use Before Endoscopy Is Associated With Low Retained Gastric Contents: A Multicenter Cross-Sectional Analysis. Am J Gastroenterol. 2025 Mar. doi: 10.14309/ajg.0000000000002969.

7. Panchal S et al. Endoscopy and Anesthesia Outcomes Associated With Glucagon-like Peptide-1 Receptor Agonist use in Patients Undergoing Outpatient Upper Endoscopy. Gastrointest Endosc. 2025 Aug. doi:10.1016/j.gie.2025.01.004.

8. Maselli DB et al. Safe Continuation of glucagon-like Peptide 1 Receptor Agonists at Endoscopy: A Case Series of 57 Adults Undergoing Endoscopic Sleeve Gastroplasty. Obes Surg. 2024 Jul. doi: 10.1007/s11695-024-07278-2.

9. Dixit AA et al. Preoperative GLP-1 Receptor Agonist Use and Risk of Postoperative Respiratory Complications. JAMA. 2024 Apr. doi: 10.1001/jama.2024.5003.

10. Hiramoto B et al. Quantified Metrics of Gastric Emptying Delay by Glucagon-Like Peptide-1 Agonists: A systematic review and meta-analysis with insights for periprocedural management. Am J Gastroenterol. 2024 Jun. doi: 10.14309/ajg.0000000000002820.

The use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) has increased over the past several years and has become a cornerstone in both diabetes and weight loss management, particularly because of its unique combination of glucose control, weight reduction potential, and cardiac and metabolic benefits. However, increased use of these agents presents a dilemma in gastrointestinal endoscopy as it pertains to their safety and management during the periprocedural period.

This review explores management of GLP-1 RAs in the periprocedural setting for endoscopic procedures based on current evidence and guidelines, highlighting gaps and future directions.

 

Pharmacology and Mechanisms of Action

GLP-1 RAs have several mechanisms of action that make them relevant in gastrointestinal endoscopy. These medications modulate glucose control via enhancement of glucose-dependent insulin secretion and reduction of postprandial glucagon, which promotes satiety and delays gastric emptying. This delay in gastric emptying mediated by vagal pathways has been postulated to increase gastric residuals, posing a risk for aspiration during anesthesia.¹

It is important to also consider the pharmacokinetics of GLP-1 RAs, as some have shorter half-lives on the order of several hours, like exenatide, while others, like semaglutide, are dosed weekly. Additionally, common side effects of GLP-1 RAs include nausea, vomiting, bloating, and early satiety, which pose challenges for patients undergoing endoscopic procedures. 

 

Current Guidelines

Various societies have published guidelines on the periprocedural use of GLP-1 RAs. The American Society of Anesthesiologist (ASA) in 2023 presented early recommendations to hold GLP-1 RAs either day of procedure or week prior depending on pharmacokinetics, because of the risk of delayed gastric emptying and increased potential for aspiration.² Soon thereafter, a multi-gastroenterology society guideline was released stating more data is needed to decide if GLP-1 RAs need to be held prior to endoscopic procedures.³

In early 2024, the American Gastroenterological Association (AGA) published a rapid clinical update that advocated for a more individualized approach, particularly in light of limited overall data for GLP-1 RAs and endoscopic procedures.⁴ In asymptomatic patients who follow typical fasting protocols for procedures, it is generally safe to proceed with endoscopy without holding GLP-1 RAs. In symptomatic patients (nausea, abdominal distension, etc), the AGA advises additional precautions, including performing transabdominal ultrasound if feasible to assess retained gastric contents. The AGA also suggests placing a patient on a clear liquid diet the day prior to the procedure — rather than holding GLP-1 RAs — as another reasonable strategy.

The guidelines continue to evolve with newer multi-society guidelines establishing best practices. While initially in 2023 the ASA did recommend holding these medications prior to endoscopy, the initial guidance was based on expert opinion with limited evidence. Newer multi-society guidance published jointly by the ASA along with various gastroenterology societies, including the AGA in December 2024, takes a more nuanced approach.⁵

The newer guidelines include two main recommendations:

1. Periprocedural management of GLP-1 RAs should be a joint decision among the procedural, anesthesia, and prescribing team balancing metabolic needs vs patient risks.

• In a low-risk patient, one that is asymptomatic and on standard dosing, among other factors, the guidance states that GLP-1 RAs can be continued.
• In higher-risk patients, the original guidance of holding a day or a week prior to endoscopic procedures should be followed.

2. Periprocedural management of GLP-1 RAs should attempt to minimize the aspiration risks loosely associated with delayed gastric emptying.

• Consider a 24-hour clear liquid diet a day prior to the procedure and transabdominal ultrasound to check gastric contents.
• It is acknowledged that this guidance is based on limited evidence and will be evolving as new medications and data are released.

Recent Clinical Studies

Although there is very little data to guide clinicians, several recent studies have been published that can direct clinical decision-making as guidelines continue to be refined and updated.

A multicenter trial of approximately 800 patients undergoing upper endoscopy found a significant difference in rates of retained gastric contents between those that underwent endoscopy who did and did not follow the ASA guidance on periprocedural management of GLP-1 RAs (12.7% vs 4.4%; P < .0001). However, there were no significant differences in rates of aborted procedures or unplanned intubations.

Furthermore, a multivariable analysis was performed controlling for GLP-1 RA type and other factors, which found the likelihood of gastric retention increased by 36% for every 1% increase in hemoglobin A1c. This study suggests that a more individualized approach to holding GLP-1 RA would be applicable rather than a universal periprocedural hold.⁶

More recently, a single-center study of nearly 600 patients undergoing upper endoscopy showed that while there were slightly increased rates of retained gastric contents (OR 3.80; P = .003) and aborted procedures (1.3% vs 0%; P = .02), the rates of adverse anesthesia events (hypoxia, etc) were similar between the groups and no cases of pulmonary aspiration were noted.7

One single-center study of 57 patients evaluated the safety of GLP-1 RAs in those undergoing endoscopic sleeve gastrectomy. GLP-1 RAs were continued on all patients, but all adhered to a liquid only diet for at least 24 hours prior to the procedure. There were no instances of retained gastric solids, aspiration, or hypoxia. This study suggests that with a 24-hour clear liquid diet and routine NPO recommendations prior to endoscopy, it would be safe to continue GLP-1 RAs. This study provides rationale for the AGA recommendation for a clear liquid diet 24 hours prior to endoscopic procedures for those on GLP-1 RAs.⁸

A study looking at those who underwent emergency surgery and endoscopy with claims data of use of GLP-1 RAs found an overall incidence of postoperative respiratory complications of 3.5% for those with GLP-1 RAs fill history vs 4.0% for those without (P = .12). Approximately 800 of the 24,000 patients identified had undergone endoscopic procedures for GI bleeding or food impaction. The study overall showed that preoperative use of GLP-1 RAs in patients undergoing surgery or endoscopy, evaluated as a combined group, was not associated with an increased risk of pulmonary complications.⁹

Lastly, a systematic review and meta-analysis that included 15 studies that quantified gastric emptying using various methods, including gastric emptying scintigraphy and acetaminophen absorption test, found that there was a quantifiable delay in gastric emptying of about 36 minutes, compared to placebo (P < .01), in patients using GLP-1 RAs. However, compared to standard periprocedural fasting, this delay is clinically insignificant and standard fasting protocols would still be appropriate for patients on GLP-1 RAs.¹⁰

These studies taken together suggest that while GLP-1 RAs can mildly increase the likelihood of retained gastric contents, there is no statistically significant increase in the risk of aspiration or other anesthesia complications. Furthermore, while decreased gastric emptying is a known effect of GLP-1 RAs, this effect may not be clinically significant in the context of standard periprocedural fasting protocols particularly when combined with a 24-hour clear liquid diet. These findings support at a minimum a more patient-specific strategy for periprocedural management of GLP-1 RAs.

 

Clinical Implications

These most recent studies, as well as prior studies and guidelines by various societies lead to a dilemma among endoscopists on proper patient counseling on GLP-1 RAs use before endoscopic procedures. Clinicians must balance the metabolic benefits of GLP-1 RAs with potential endoscopic complications and risks.

Holding therapy theoretically decreases aspiration risk and pulmonary complications, though evidence remains low to support this. Holding medication, however, affects glycemic control leading to potential rebound hyperglycemia which may impact and delay plans for endoscopy. With growing indications for the use of GLP-1 RAs, a more tailored patient-centered treatment plan may be required, especially with consideration of procedure indication and comorbidities.

Currently, practice patterns at different institutions vary widely, making standardization much more difficult. Some centers have opted to follow ASA guidelines of holding these medications up to 1 week prior to procedures, while others have continued therapy with no pre-procedural adjustments. This leaves endoscopists to deal with the downstream effects of inconvenience to patients, care delays, and financial considerations if procedures are postponed related to GLP-1 RAs use.

 

Future Directions

Future studies are needed to make further evidence-based recommendations. Studies should focus on stratifying risks and recommendations based on procedure type (EGD, colonoscopy, etc). More widespread implementation of gastric ultrasound can assist in real-time decision-making, albeit this would require expertise and dedicated time within the pre-procedural workflow. Randomized controlled trials comparing outcomes of patients who continue GLP-1 RAs vs those who discontinue stratified by baseline risk will be instrumental for making concrete guidelines that provide clarity on periprocedural management of GLP-1 RAs.

Conclusion

The periprocedural management of GLP-1 RAs remains a controversial topic that presents unique challenges in endoscopy. Several guidelines have been released by various stakeholders including anesthesiologists, gastroenterologists, and other prescribing providers. Clinical data remains limited with no robust evidence available to suggest that gastric emptying delays caused by GLP-1 RAs prior to endoscopic procedures significantly increases risk of aspiration, pulmonary complications, or other comorbidities. Evolving multi-society guidelines will be important to establish more consistent practices with reassessment of the data as new studies emerge. A multidisciplinary, individualized patient approach may be the best strategy for managing GLP-1 RAs for patients undergoing endoscopic procedures.

Dr. Sekar and Dr. Asamoah are based in the department of gastroenterology at MedStar Georgetown University Hospital, Washington, D.C. Dr. Sekar reports no conflicts of interest in regard to this article. Dr. Asamoah serves on the Johnson & Johnson advisory board for inflammatory bowel disease–related therapies.

References

1. Halim MA et al. Glucagon-Like Peptide-1 Inhibits Prandial Gastrointestinal Motility Through Myenteric Neuronal Mechanisms in Humans. J Clin Endocrinol Metab. 2018 Feb. doi: 10.1210/jc.2017-02006.

2. American Society of Anesthesiologists. American Society of Anesthesiologists releases consensus-based guidance on preoperative use of GLP-1 receptor agonists. 2023 Jun 20. www.asahq.org/about-asa/newsroom/news-releases/2023/06/american-society-of-anesthesiologists-consensus-based-guidance-on-preoperative

3. American Gastroenterological Association. GI multi-society statement regarding GLP-1 agonists and endoscopy. 2023 Jul 25. gastro.org/news/gi-multi-society-statement-regarding-glp-1-agonists-and-endoscopy/.

4. Hashash JG et al. AGA Rapid Clinical Practice Update on the Management of Patients Taking GLP-1 Receptor Agonists Prior to Endoscopy: Communication. Clin Gastroenterol Hepatol. 2024 Apr. doi: 10.1016/j.cgh.2023.11.002.

5. Kindel TL et al; American Gastroenterological Association; American Society for Metabolic and Bariatric Surgery; American Society of Anesthesiologists; International Society of Perioperative Care of Patients with Obesity; Society of American Gastrointestinal and Endoscopic Surgeons. Multi-society Clinical Practice Guidance for the Safe Use of Glucagon-like Peptide-1 Receptor Agonists in the Perioperative Period. Clin Gastroenterol Hepatol. 2024 Oct. doi: 10.1016/j.cgh.2024.10.003.

6. Phan J et al. Glucagon-Like Peptide Receptor Agonists Use Before Endoscopy Is Associated With Low Retained Gastric Contents: A Multicenter Cross-Sectional Analysis. Am J Gastroenterol. 2025 Mar. doi: 10.14309/ajg.0000000000002969.

7. Panchal S et al. Endoscopy and Anesthesia Outcomes Associated With Glucagon-like Peptide-1 Receptor Agonist use in Patients Undergoing Outpatient Upper Endoscopy. Gastrointest Endosc. 2025 Aug. doi:10.1016/j.gie.2025.01.004.

8. Maselli DB et al. Safe Continuation of glucagon-like Peptide 1 Receptor Agonists at Endoscopy: A Case Series of 57 Adults Undergoing Endoscopic Sleeve Gastroplasty. Obes Surg. 2024 Jul. doi: 10.1007/s11695-024-07278-2.

9. Dixit AA et al. Preoperative GLP-1 Receptor Agonist Use and Risk of Postoperative Respiratory Complications. JAMA. 2024 Apr. doi: 10.1001/jama.2024.5003.

10. Hiramoto B et al. Quantified Metrics of Gastric Emptying Delay by Glucagon-Like Peptide-1 Agonists: A systematic review and meta-analysis with insights for periprocedural management. Am J Gastroenterol. 2024 Jun. doi: 10.14309/ajg.0000000000002820.

Patients with breast cancer who undergo chemotherapy may face an increased risk for brain atrophy and cognitive decline, new findings from a pilot study suggest.

Memory problems in patients with cancer may not stem solely from stress or anxiety related to their diagnosis but could reflect underlying changes in brain structure, study investigator Paul Edison, PhD, MPhil, professor of neuroscience and clinical professor of neurology at Imperial College London, England, told this news organization.

While the findings suggest that chemotherapy may contribute to neuronal damage, the researchers noted that many aspects of the relationship between treatment and brain changes remain unclear.

Edison highlighted three key areas that require further investigation — uncovering the mechanisms driving brain atrophy, determining the proportion of patients affected, and identifying effective prevention strategies.

Another investigator on the study, Laura Kenny, MD, PhD, associate professor and consultant medical oncologist at Imperial College London, noted that the issue has received limited attention to date but expressed hope that the findings will raise awareness and encourage further research, given its clinical importance.

The findings were presented on July 29 at the Alzheimer’s Association International Conference (AAIC) 2025.

 

Investigating Cognitive Impact

Advances in chemotherapeutic agents have improved survival rates in patients with cancer. However, challenges persist regarding the long-term impact of these drugs.

Chemotherapy-associated cognitive impairment, often referred to as “brain fog” or “chemobrain,” affects approximately one third of patients with breast cancer following treatment.

While cognitive decline resolves within 12 months for some patients, others experience persistent effects that may elevate the risk for neurodegenerative conditions, Edison explained.

To evaluate the impact of chemotherapy on the brain, investigators studied 328 women with nonmetastatic breast cancer who had undergone chemotherapy within the past 12 months.

Patients received either anthracycline — a drug derived from the Streptomyces peucetius bacterium — or taxanes such as docetaxel and paclitaxel, both commonly used in breast cancer treatment, or a combination of these agents. In addition, some patients may also have had hormone therapy at some point during treatment, said Kenny.

Participants completed neurocognitive prescreening tests every 3 months using a specialized artificial intelligence–driven platform, allowing them to take detailed memory assessments online from home.

Among those prescreened, 18 individuals with lower neurocognitive scores (mean age, 55 years) and 19 cognitively normal control individuals without breast cancer (mean age, 67 years) underwent comprehensive, in-person, neurocognitive evaluations and MRI scans.

Researchers analyzed the scans using region of interest (ROI) and voxel-based morphometry (VBM), which uses sophisticated computer software, to assess gray matter volumes and surface areas.

The ROI analysis revealed significant reductions in gray matter volume (measured in mm³) and surface area (measured in mm²) among patients experiencing chemobrain, particularly affecting the isthmus cingulate and pars opercularis, with changes extending into the orbitofrontal and temporal regions.

 

Significant Atrophy

The VBM analysis confirmed significant atrophy in the frontal, parietal, and cingulate regions of patients with chemobrain compared with control individuals (P < .05). Edison noted that this pattern overlaps with brain changes typically observed in Alzheimer’s disease and vascular cognitive impairment.

For both analyses, “we demonstrated there is some amount of shrinkage in the brain among patients with chemobrain,” he said. “The fact that controls are older means the results are even more significant as there’s more brain atrophy as people age.”

Some of the affected brain regions may be linked to impaired memory, a hallmark of Alzheimer’s disease, but Edison cautioned that given the small sample size this finding should be interpreted with caution.

While the analysis demonstrated overall lower brain volumes in patients with “chemobrain” compared with controls, Edison emphasized that this finding reflects a single time point and does not indicate brain shrinkage over time.

Other events, including stroke — can also cause brain changes.

Edison highlighted the importance of determining the significance of these brain changes, how they affect patients and whether they can be prevented.

In-person neurocognitive testing revealed significantly reduced semantic and verbal fluency, as well as lower Mini-Mental State Examination scores in patients with chemobrain. Edison noted that these results support the MRI findings.

The team plans to follow patients to track brain changes and memory recovery, Kenny said. While patients with breast cancer are a common focus, the researchers intend to expand the study to other cancers in both men and women, said Kenny. 

Based on discussions with her oncology colleagues, Kenny noted that many patients anecdotally report experiencing memory problems during chemotherapy.

 

More Research Needed

Commenting for this news organization, Rebecca M. Edelmayer, PhD, vice president, scientific engagement, at the Alzheimer’s Association, said the research may help shed light on why women are more likely to develop dementia than men.

For years now, experts have been trying to figure out what puts women at higher risk for AD and other dementias, said Edelmayer.

“We still don’t understand whether this involves biologically driven risk factors or socially driven risk factors.”

Research linking treatments for other health conditions to increased memory problems may offer some clues, she noted, suggesting a potential avenue for further investigation into the intersection of chemotherapy and neurodegenerative diseases such as Alzheimer’s.

However, Edelmayer emphasized that this line of research is still in its infancy. Much more work is needed to determine whether there is a direct cause-and-effect relationship with specific chemotherapy drugs, and whether some patients may already be predisposed or at higher risk for cognitive decline, she said.

Also commenting for this news organization, Eric Brown, MD, associate scientist and associate chief of geriatric psychiatry at the Centre for Addiction and Mental Health in Toronto, raised concerns about the study’s design.

One issue, he noted, is that the researchers did not image all patients who received chemotherapy but instead selected those with the most significant cognitive impairment. As a result, the findings may not have reflected outcomes in the average post-chemotherapy patients but rather represent the most severely affected subgroup.

Brown pointed out that the study did not clarify whether this subgroup had comorbid conditions. It’s possible, he said, that some individuals may have had Alzheimer’s disease or other forms of dementia unrelated to chemotherapy.

He agreed that tracking longitudinal changes in both cognitive scores and neuroimaging — comparing patients who receive chemotherapy with those who do not — would be a valuable next step.

The investigators, Edelmayer, and Brown reported no relevant conflicts of interest. A version of this article first appeared on Medscape.com.

Patients with breast cancer who undergo chemotherapy may face an increased risk for brain atrophy and cognitive decline, new findings from a pilot study suggest.

Memory problems in patients with cancer may not stem solely from stress or anxiety related to their diagnosis but could reflect underlying changes in brain structure, study investigator Paul Edison, PhD, MPhil, professor of neuroscience and clinical professor of neurology at Imperial College London, England, told this news organization.

While the findings suggest that chemotherapy may contribute to neuronal damage, the researchers noted that many aspects of the relationship between treatment and brain changes remain unclear.

Edison highlighted three key areas that require further investigation — uncovering the mechanisms driving brain atrophy, determining the proportion of patients affected, and identifying effective prevention strategies.

Another investigator on the study, Laura Kenny, MD, PhD, associate professor and consultant medical oncologist at Imperial College London, noted that the issue has received limited attention to date but expressed hope that the findings will raise awareness and encourage further research, given its clinical importance.

The findings were presented on July 29 at the Alzheimer’s Association International Conference (AAIC) 2025.

 

Investigating Cognitive Impact

Advances in chemotherapeutic agents have improved survival rates in patients with cancer. However, challenges persist regarding the long-term impact of these drugs.

Chemotherapy-associated cognitive impairment, often referred to as “brain fog” or “chemobrain,” affects approximately one third of patients with breast cancer following treatment.

While cognitive decline resolves within 12 months for some patients, others experience persistent effects that may elevate the risk for neurodegenerative conditions, Edison explained.

To evaluate the impact of chemotherapy on the brain, investigators studied 328 women with nonmetastatic breast cancer who had undergone chemotherapy within the past 12 months.

Patients received either anthracycline — a drug derived from the Streptomyces peucetius bacterium — or taxanes such as docetaxel and paclitaxel, both commonly used in breast cancer treatment, or a combination of these agents. In addition, some patients may also have had hormone therapy at some point during treatment, said Kenny.

Participants completed neurocognitive prescreening tests every 3 months using a specialized artificial intelligence–driven platform, allowing them to take detailed memory assessments online from home.

Among those prescreened, 18 individuals with lower neurocognitive scores (mean age, 55 years) and 19 cognitively normal control individuals without breast cancer (mean age, 67 years) underwent comprehensive, in-person, neurocognitive evaluations and MRI scans.

Researchers analyzed the scans using region of interest (ROI) and voxel-based morphometry (VBM), which uses sophisticated computer software, to assess gray matter volumes and surface areas.

The ROI analysis revealed significant reductions in gray matter volume (measured in mm³) and surface area (measured in mm²) among patients experiencing chemobrain, particularly affecting the isthmus cingulate and pars opercularis, with changes extending into the orbitofrontal and temporal regions.

 

Significant Atrophy

The VBM analysis confirmed significant atrophy in the frontal, parietal, and cingulate regions of patients with chemobrain compared with control individuals (P < .05). Edison noted that this pattern overlaps with brain changes typically observed in Alzheimer’s disease and vascular cognitive impairment.

For both analyses, “we demonstrated there is some amount of shrinkage in the brain among patients with chemobrain,” he said. “The fact that controls are older means the results are even more significant as there’s more brain atrophy as people age.”

Some of the affected brain regions may be linked to impaired memory, a hallmark of Alzheimer’s disease, but Edison cautioned that given the small sample size this finding should be interpreted with caution.

While the analysis demonstrated overall lower brain volumes in patients with “chemobrain” compared with controls, Edison emphasized that this finding reflects a single time point and does not indicate brain shrinkage over time.

Other events, including stroke — can also cause brain changes.

Edison highlighted the importance of determining the significance of these brain changes, how they affect patients and whether they can be prevented.

In-person neurocognitive testing revealed significantly reduced semantic and verbal fluency, as well as lower Mini-Mental State Examination scores in patients with chemobrain. Edison noted that these results support the MRI findings.

The team plans to follow patients to track brain changes and memory recovery, Kenny said. While patients with breast cancer are a common focus, the researchers intend to expand the study to other cancers in both men and women, said Kenny. 

Based on discussions with her oncology colleagues, Kenny noted that many patients anecdotally report experiencing memory problems during chemotherapy.

 

More Research Needed

Commenting for this news organization, Rebecca M. Edelmayer, PhD, vice president, scientific engagement, at the Alzheimer’s Association, said the research may help shed light on why women are more likely to develop dementia than men.

For years now, experts have been trying to figure out what puts women at higher risk for AD and other dementias, said Edelmayer.

“We still don’t understand whether this involves biologically driven risk factors or socially driven risk factors.”

Research linking treatments for other health conditions to increased memory problems may offer some clues, she noted, suggesting a potential avenue for further investigation into the intersection of chemotherapy and neurodegenerative diseases such as Alzheimer’s.

However, Edelmayer emphasized that this line of research is still in its infancy. Much more work is needed to determine whether there is a direct cause-and-effect relationship with specific chemotherapy drugs, and whether some patients may already be predisposed or at higher risk for cognitive decline, she said.

Also commenting for this news organization, Eric Brown, MD, associate scientist and associate chief of geriatric psychiatry at the Centre for Addiction and Mental Health in Toronto, raised concerns about the study’s design.

One issue, he noted, is that the researchers did not image all patients who received chemotherapy but instead selected those with the most significant cognitive impairment. As a result, the findings may not have reflected outcomes in the average post-chemotherapy patients but rather represent the most severely affected subgroup.

Brown pointed out that the study did not clarify whether this subgroup had comorbid conditions. It’s possible, he said, that some individuals may have had Alzheimer’s disease or other forms of dementia unrelated to chemotherapy.

He agreed that tracking longitudinal changes in both cognitive scores and neuroimaging — comparing patients who receive chemotherapy with those who do not — would be a valuable next step.

The investigators, Edelmayer, and Brown reported no relevant conflicts of interest. A version of this article first appeared on Medscape.com.

Patients with breast cancer who undergo chemotherapy may face an increased risk for brain atrophy and cognitive decline, new findings from a pilot study suggest.

Memory problems in patients with cancer may not stem solely from stress or anxiety related to their diagnosis but could reflect underlying changes in brain structure, study investigator Paul Edison, PhD, MPhil, professor of neuroscience and clinical professor of neurology at Imperial College London, England, told this news organization.

While the findings suggest that chemotherapy may contribute to neuronal damage, the researchers noted that many aspects of the relationship between treatment and brain changes remain unclear.

Edison highlighted three key areas that require further investigation — uncovering the mechanisms driving brain atrophy, determining the proportion of patients affected, and identifying effective prevention strategies.

Another investigator on the study, Laura Kenny, MD, PhD, associate professor and consultant medical oncologist at Imperial College London, noted that the issue has received limited attention to date but expressed hope that the findings will raise awareness and encourage further research, given its clinical importance.

The findings were presented on July 29 at the Alzheimer’s Association International Conference (AAIC) 2025.

 

Investigating Cognitive Impact

Advances in chemotherapeutic agents have improved survival rates in patients with cancer. However, challenges persist regarding the long-term impact of these drugs.

Chemotherapy-associated cognitive impairment, often referred to as “brain fog” or “chemobrain,” affects approximately one third of patients with breast cancer following treatment.

While cognitive decline resolves within 12 months for some patients, others experience persistent effects that may elevate the risk for neurodegenerative conditions, Edison explained.

To evaluate the impact of chemotherapy on the brain, investigators studied 328 women with nonmetastatic breast cancer who had undergone chemotherapy within the past 12 months.

Patients received either anthracycline — a drug derived from the Streptomyces peucetius bacterium — or taxanes such as docetaxel and paclitaxel, both commonly used in breast cancer treatment, or a combination of these agents. In addition, some patients may also have had hormone therapy at some point during treatment, said Kenny.

Participants completed neurocognitive prescreening tests every 3 months using a specialized artificial intelligence–driven platform, allowing them to take detailed memory assessments online from home.

Among those prescreened, 18 individuals with lower neurocognitive scores (mean age, 55 years) and 19 cognitively normal control individuals without breast cancer (mean age, 67 years) underwent comprehensive, in-person, neurocognitive evaluations and MRI scans.

Researchers analyzed the scans using region of interest (ROI) and voxel-based morphometry (VBM), which uses sophisticated computer software, to assess gray matter volumes and surface areas.

The ROI analysis revealed significant reductions in gray matter volume (measured in mm³) and surface area (measured in mm²) among patients experiencing chemobrain, particularly affecting the isthmus cingulate and pars opercularis, with changes extending into the orbitofrontal and temporal regions.

 

Significant Atrophy

The VBM analysis confirmed significant atrophy in the frontal, parietal, and cingulate regions of patients with chemobrain compared with control individuals (P < .05). Edison noted that this pattern overlaps with brain changes typically observed in Alzheimer’s disease and vascular cognitive impairment.

For both analyses, “we demonstrated there is some amount of shrinkage in the brain among patients with chemobrain,” he said. “The fact that controls are older means the results are even more significant as there’s more brain atrophy as people age.”

Some of the affected brain regions may be linked to impaired memory, a hallmark of Alzheimer’s disease, but Edison cautioned that given the small sample size this finding should be interpreted with caution.

While the analysis demonstrated overall lower brain volumes in patients with “chemobrain” compared with controls, Edison emphasized that this finding reflects a single time point and does not indicate brain shrinkage over time.

Other events, including stroke — can also cause brain changes.

Edison highlighted the importance of determining the significance of these brain changes, how they affect patients and whether they can be prevented.

In-person neurocognitive testing revealed significantly reduced semantic and verbal fluency, as well as lower Mini-Mental State Examination scores in patients with chemobrain. Edison noted that these results support the MRI findings.

The team plans to follow patients to track brain changes and memory recovery, Kenny said. While patients with breast cancer are a common focus, the researchers intend to expand the study to other cancers in both men and women, said Kenny. 

Based on discussions with her oncology colleagues, Kenny noted that many patients anecdotally report experiencing memory problems during chemotherapy.

 

More Research Needed

Commenting for this news organization, Rebecca M. Edelmayer, PhD, vice president, scientific engagement, at the Alzheimer’s Association, said the research may help shed light on why women are more likely to develop dementia than men.

For years now, experts have been trying to figure out what puts women at higher risk for AD and other dementias, said Edelmayer.

“We still don’t understand whether this involves biologically driven risk factors or socially driven risk factors.”

Research linking treatments for other health conditions to increased memory problems may offer some clues, she noted, suggesting a potential avenue for further investigation into the intersection of chemotherapy and neurodegenerative diseases such as Alzheimer’s.

However, Edelmayer emphasized that this line of research is still in its infancy. Much more work is needed to determine whether there is a direct cause-and-effect relationship with specific chemotherapy drugs, and whether some patients may already be predisposed or at higher risk for cognitive decline, she said.

Also commenting for this news organization, Eric Brown, MD, associate scientist and associate chief of geriatric psychiatry at the Centre for Addiction and Mental Health in Toronto, raised concerns about the study’s design.

One issue, he noted, is that the researchers did not image all patients who received chemotherapy but instead selected those with the most significant cognitive impairment. As a result, the findings may not have reflected outcomes in the average post-chemotherapy patients but rather represent the most severely affected subgroup.

Brown pointed out that the study did not clarify whether this subgroup had comorbid conditions. It’s possible, he said, that some individuals may have had Alzheimer’s disease or other forms of dementia unrelated to chemotherapy.

He agreed that tracking longitudinal changes in both cognitive scores and neuroimaging — comparing patients who receive chemotherapy with those who do not — would be a valuable next step.

The investigators, Edelmayer, and Brown reported no relevant conflicts of interest. A version of this article first appeared on Medscape.com.

Genetic sequencing of peptides in rebound virus in individuals with HIV who had analytic treatment interruptions (ATIs) confirmed the peptides’ expression in HIV-1 infection, according to data presented at the International AIDS Society Conference on HIV Science. 

Previous research has shown that HIV-specific CD8 T-cell responses directed against five genetically conserved HIV-1 protein regions (Gag, Pol, Vif, Vpr, and Env) are associated with viral control, Josefina Marín-Rojas, PhD, Faculty of Medicine and Health, University of Sydney, and colleagues wrote in their abstract.

However, data on whether these peptides are expressed in rebound virus among individuals with HIV who experienced ATI are limited, they wrote.

The researchers applied an immunoinformatics analysis pipeline (IMAP) to select 182 peptides (IMAP-peptides) from structurally important and mutation-intolerant regions of HIV-1 proteins, senior author Sarah Palmer, PhD, co-director of the Centre for Virus Research at the Westmead Institute for Medical Research and professor in the Faculty of Medicine and Health at the University of Sydney, said in an interview.

“Our studies indicate if the immune system targets these structurally important and mutation-intolerant regions of HIV-1 proteins, this can contribute to virological control in the absence of HIV-1 therapy,” she explained.

The researchers reviewed data from the PULSE clinical trial, which included 68 men who have sex with men living with HIV in Australia. The men underwent three consecutive ATIs. A total of seven participants’ transiently controlled HIV rebound during the third ATI. The researchers examined whether the IMAP peptides were present in the HIV-1 RNA sequences of the rebound virus in four noncontrollers (patients who had viral rebound in all three ATIs) and five of the seven transient controllers who showed viral control during the third ATI.

The technique of near full-length HIV-1 RNA sequencing of rebound virus from three noncontrollers and two transient controllers identified the Gag, Pol, Vif, Vpr, and Env IMAP-peptides in 52%-100% of the viral sequences obtained from these participants across three ATI timepoints.

“We assumed that cells from people living with HIV that experience virological control after treatment interruption would have the immune response to our IMAP-peptides that we observed; however, we are amazed and encouraged by the level and extent of this immune response,” Palmer told this news organization.

The researchers also compared CD8 T-cell response between the IMAP peptides and a control peptide pool without the IMAP peptides.

The CD8 T-cells from three transient controllers had a 15- to 53-fold higher effector response to the IMAP-peptides than the CD8 T-cells from two noncontrollers, the researchers wrote in their abstract. The relative response to the IMAP-peptides in noncontrollers was 20 times lower than that to the control peptides, but the IMAP-peptide response in the transient controllers group was similar to that in the control group, the authors noted.

The results highlight the potential of IMAP in developing treatment strategies. Although the results are too preliminary to impact clinical practice at this time, the findings from the current study could lead to the development of an mRNA vaccine to clear HIV-infected cells from people living with HIV, Palmer told this news organization.

“Our next steps include developing and testing mRNA vaccine constructs that contain our IMAP-peptides to assess the immune response of cells from people living with HIV to these vaccines,” Palmer said. “From there we will conduct studies of the most promising mRNA vaccine constructs in a humanized mouse model,” she said.

 

Data Enhance Understanding of Immunity

The current study may provide information that can significantly impact understanding of the immune responses to HIV, David J. Cennimo, MD, associate professor of medicine and pediatrics in the Division of Infectious Disease at Rutgers New Jersey Medical School, Newark, New Jersey, said in an interview.

“The investigators looked at highly conserved regions of multiple HIV proteins,” said Cennimo, who was not involved in the study. “Conserved regions and antibody responses to them may play a role in controlling HIV viral replication and rebound,” Cennimo told this news organization. “The investigators showed these regions were present in rebounding viremia, and individuals that exhibited greater immune recognition of these regions suppressed rebound viremia longer, and perhaps targeting these regions could impact HIV prevention or cure strategies,” he said.

Secondarily, the study showed the success of the novel technique (IMAP) to identify conserved peptides, said Cennimo. The technique could potentially be applied to other viruses that mutate to escape host response, he said.The study was funded by the U.S. National Institutes of Health, the Foundation for AIDS Research, the Australian National Health and Medical Research Council, and Sandra and David Ansley. The researchers and Cennimo disclosed no financial conflicts of interest.

A version of this article first appeared on Medscape.com.

Genetic sequencing of peptides in rebound virus in individuals with HIV who had analytic treatment interruptions (ATIs) confirmed the peptides’ expression in HIV-1 infection, according to data presented at the International AIDS Society Conference on HIV Science. 

Previous research has shown that HIV-specific CD8 T-cell responses directed against five genetically conserved HIV-1 protein regions (Gag, Pol, Vif, Vpr, and Env) are associated with viral control, Josefina Marín-Rojas, PhD, Faculty of Medicine and Health, University of Sydney, and colleagues wrote in their abstract.

However, data on whether these peptides are expressed in rebound virus among individuals with HIV who experienced ATI are limited, they wrote.

The researchers applied an immunoinformatics analysis pipeline (IMAP) to select 182 peptides (IMAP-peptides) from structurally important and mutation-intolerant regions of HIV-1 proteins, senior author Sarah Palmer, PhD, co-director of the Centre for Virus Research at the Westmead Institute for Medical Research and professor in the Faculty of Medicine and Health at the University of Sydney, said in an interview.

“Our studies indicate if the immune system targets these structurally important and mutation-intolerant regions of HIV-1 proteins, this can contribute to virological control in the absence of HIV-1 therapy,” she explained.

The researchers reviewed data from the PULSE clinical trial, which included 68 men who have sex with men living with HIV in Australia. The men underwent three consecutive ATIs. A total of seven participants’ transiently controlled HIV rebound during the third ATI. The researchers examined whether the IMAP peptides were present in the HIV-1 RNA sequences of the rebound virus in four noncontrollers (patients who had viral rebound in all three ATIs) and five of the seven transient controllers who showed viral control during the third ATI.

The technique of near full-length HIV-1 RNA sequencing of rebound virus from three noncontrollers and two transient controllers identified the Gag, Pol, Vif, Vpr, and Env IMAP-peptides in 52%-100% of the viral sequences obtained from these participants across three ATI timepoints.

“We assumed that cells from people living with HIV that experience virological control after treatment interruption would have the immune response to our IMAP-peptides that we observed; however, we are amazed and encouraged by the level and extent of this immune response,” Palmer told this news organization.

The researchers also compared CD8 T-cell response between the IMAP peptides and a control peptide pool without the IMAP peptides.

The CD8 T-cells from three transient controllers had a 15- to 53-fold higher effector response to the IMAP-peptides than the CD8 T-cells from two noncontrollers, the researchers wrote in their abstract. The relative response to the IMAP-peptides in noncontrollers was 20 times lower than that to the control peptides, but the IMAP-peptide response in the transient controllers group was similar to that in the control group, the authors noted.

The results highlight the potential of IMAP in developing treatment strategies. Although the results are too preliminary to impact clinical practice at this time, the findings from the current study could lead to the development of an mRNA vaccine to clear HIV-infected cells from people living with HIV, Palmer told this news organization.

“Our next steps include developing and testing mRNA vaccine constructs that contain our IMAP-peptides to assess the immune response of cells from people living with HIV to these vaccines,” Palmer said. “From there we will conduct studies of the most promising mRNA vaccine constructs in a humanized mouse model,” she said.

 

Data Enhance Understanding of Immunity

The current study may provide information that can significantly impact understanding of the immune responses to HIV, David J. Cennimo, MD, associate professor of medicine and pediatrics in the Division of Infectious Disease at Rutgers New Jersey Medical School, Newark, New Jersey, said in an interview.

“The investigators looked at highly conserved regions of multiple HIV proteins,” said Cennimo, who was not involved in the study. “Conserved regions and antibody responses to them may play a role in controlling HIV viral replication and rebound,” Cennimo told this news organization. “The investigators showed these regions were present in rebounding viremia, and individuals that exhibited greater immune recognition of these regions suppressed rebound viremia longer, and perhaps targeting these regions could impact HIV prevention or cure strategies,” he said.

Secondarily, the study showed the success of the novel technique (IMAP) to identify conserved peptides, said Cennimo. The technique could potentially be applied to other viruses that mutate to escape host response, he said.The study was funded by the U.S. National Institutes of Health, the Foundation for AIDS Research, the Australian National Health and Medical Research Council, and Sandra and David Ansley. The researchers and Cennimo disclosed no financial conflicts of interest.

A version of this article first appeared on Medscape.com.

Genetic sequencing of peptides in rebound virus in individuals with HIV who had analytic treatment interruptions (ATIs) confirmed the peptides’ expression in HIV-1 infection, according to data presented at the International AIDS Society Conference on HIV Science. 

Previous research has shown that HIV-specific CD8 T-cell responses directed against five genetically conserved HIV-1 protein regions (Gag, Pol, Vif, Vpr, and Env) are associated with viral control, Josefina Marín-Rojas, PhD, Faculty of Medicine and Health, University of Sydney, and colleagues wrote in their abstract.

However, data on whether these peptides are expressed in rebound virus among individuals with HIV who experienced ATI are limited, they wrote.

The researchers applied an immunoinformatics analysis pipeline (IMAP) to select 182 peptides (IMAP-peptides) from structurally important and mutation-intolerant regions of HIV-1 proteins, senior author Sarah Palmer, PhD, co-director of the Centre for Virus Research at the Westmead Institute for Medical Research and professor in the Faculty of Medicine and Health at the University of Sydney, said in an interview.

“Our studies indicate if the immune system targets these structurally important and mutation-intolerant regions of HIV-1 proteins, this can contribute to virological control in the absence of HIV-1 therapy,” she explained.

The researchers reviewed data from the PULSE clinical trial, which included 68 men who have sex with men living with HIV in Australia. The men underwent three consecutive ATIs. A total of seven participants’ transiently controlled HIV rebound during the third ATI. The researchers examined whether the IMAP peptides were present in the HIV-1 RNA sequences of the rebound virus in four noncontrollers (patients who had viral rebound in all three ATIs) and five of the seven transient controllers who showed viral control during the third ATI.

The technique of near full-length HIV-1 RNA sequencing of rebound virus from three noncontrollers and two transient controllers identified the Gag, Pol, Vif, Vpr, and Env IMAP-peptides in 52%-100% of the viral sequences obtained from these participants across three ATI timepoints.

“We assumed that cells from people living with HIV that experience virological control after treatment interruption would have the immune response to our IMAP-peptides that we observed; however, we are amazed and encouraged by the level and extent of this immune response,” Palmer told this news organization.

The researchers also compared CD8 T-cell response between the IMAP peptides and a control peptide pool without the IMAP peptides.

The CD8 T-cells from three transient controllers had a 15- to 53-fold higher effector response to the IMAP-peptides than the CD8 T-cells from two noncontrollers, the researchers wrote in their abstract. The relative response to the IMAP-peptides in noncontrollers was 20 times lower than that to the control peptides, but the IMAP-peptide response in the transient controllers group was similar to that in the control group, the authors noted.

The results highlight the potential of IMAP in developing treatment strategies. Although the results are too preliminary to impact clinical practice at this time, the findings from the current study could lead to the development of an mRNA vaccine to clear HIV-infected cells from people living with HIV, Palmer told this news organization.

“Our next steps include developing and testing mRNA vaccine constructs that contain our IMAP-peptides to assess the immune response of cells from people living with HIV to these vaccines,” Palmer said. “From there we will conduct studies of the most promising mRNA vaccine constructs in a humanized mouse model,” she said.

 

Data Enhance Understanding of Immunity

The current study may provide information that can significantly impact understanding of the immune responses to HIV, David J. Cennimo, MD, associate professor of medicine and pediatrics in the Division of Infectious Disease at Rutgers New Jersey Medical School, Newark, New Jersey, said in an interview.

“The investigators looked at highly conserved regions of multiple HIV proteins,” said Cennimo, who was not involved in the study. “Conserved regions and antibody responses to them may play a role in controlling HIV viral replication and rebound,” Cennimo told this news organization. “The investigators showed these regions were present in rebounding viremia, and individuals that exhibited greater immune recognition of these regions suppressed rebound viremia longer, and perhaps targeting these regions could impact HIV prevention or cure strategies,” he said.

Secondarily, the study showed the success of the novel technique (IMAP) to identify conserved peptides, said Cennimo. The technique could potentially be applied to other viruses that mutate to escape host response, he said.The study was funded by the U.S. National Institutes of Health, the Foundation for AIDS Research, the Australian National Health and Medical Research Council, and Sandra and David Ansley. The researchers and Cennimo disclosed no financial conflicts of interest.

A version of this article first appeared on Medscape.com.

RAPID CITY, S.D. — Cassandra Palmier had been meaning to get her son the second and final dose of the measles vaccine. But car problems made it difficult to get to the doctor.

So she pounced on the opportunity to get him vaccinated after learning that a mobile clinic would be visiting her neighborhood.

“I was definitely concerned about the epidemic and the measles,” Palmier, a member of the Oglala Sioux Tribe, said at the June event. “I wanted to do my part.”

So did her son, Makaito Cuny.

“I’m not going to be scared,” the 5-year-old announced as he walked onto the bus containing the clinic and hopped into an exam chair.

Makaito sat still as a nurse gave him the shot in his arm. “I did it!” he said while smiling at his mother.

The vaccine clinic was hosted by the Great Plains Tribal Leaders’ Health Board, which serves tribes across Iowa, Nebraska, and the Dakotas. It’s one way Native American tribes and organizations are responding to concerns about low measles vaccination rates and patients’ difficulty accessing health care as the disease spreads across the country.

Meghan O’Connell, the board’s chief public health officer, said it is also working with tribes that want to host vaccine clinics.

Elsewhere, tribal health organizations have launched social media campaigns, are making sure health providers are vaccinated, and are reaching out to the parents of unvaccinated children.

This spring, Project ECHO at the University of New Mexico hosted an online video series about measles aimed at health care professionals and organizations that serve Native American communities. The presenters outlined the basics of measles diagnosis and treatment, discussed culturally relevant communication strategies, and shared how tribes are responding to the outbreak.

Participants also strategized about ways to improve vaccination rates, said Harry Brown, a physician and an epidemiologist for the United South and Eastern Tribes, a nonprofit that works with 33 tribes in the Atlantic Coast and Southeast regions.

“It’s a pretty hot topic right now in Indian Country and I think a lot of people are being proactive,” he said.

Measles can survive for up to two hours in the air in a space where an infected person has been, sickening up to 90% of people who aren’t vaccinated, according to the Centers for Disease Control and Prevention.

The U.S. has had 1,319 confirmed cases of measles this year as of July 23, according to the CDC. It’s the largest outbreak in the U.S. since 1992. Ninety-two percent of the 2025 cases involve unvaccinated patients or people with an unknown vaccination status. Three people had died in the U.S. and 165 had been hospitalized as of July 23.

O’Connell said data on Native Americans’ vaccination rates is imperfect but that it suggests a lower percentage of them have received measles shots than the overall U.S. population.

The limited national data on measles vaccination rates for Native Americans is based on small surveys of people who self-identify as Native American. Some show that Native Americans have slightly lower measles vaccination rates, while others show significant gaps.

Data from some states, including South Dakota and Montana, shows that Native Americans are less likely than white children to be vaccinated on schedule.

The national measles vaccination rate is significantly lower for Native Americans who use the mostly rural Indian Health Service. About 76% of children 16 to 27 months old had gotten the first shot, according to data collected by the agency during recent patient visits at 156 clinics. That’s a 10-percentage-point drop from 10 years ago.

But the IHS data shows that its patients are at least as likely as other children to have received both recommended measles shots by the time they’re 17. O’Connell said it’s unclear if currently unvaccinated patients will continue the trend of eventually getting up to date on their shots or if they will remain unvaccinated.

The immunization rate is probably higher for older children since schools require students to get vaccinated unless they have an exemption, Brown said. He said it’s important that parents get their children vaccinated on time, when they’re young and more at risk of being hospitalized or dying from the disease.

Native Americans may have lower vaccination rates due to the challenges they face in accessing shots and other health care, O’Connell said. Those on rural reservations may be an hour or more from a clinic. Or, like Palmier, they may not have reliable transportation.

Another reason, O’Connell said, is that some Native Americans distrust the Indian Health Service, which is chronically underfunded and understaffed. If the only nearby health care facility is run by the agency, patients may delay or skip care.

O’Connell and Brown said vaccine skepticism and mistrust of the entire health care system are growing in Native American communities, as has occurred elsewhere nationwide.

“Prior to social media, I think our population was pretty trustful of childhood vaccination. And American Indians have a long history of being severely impacted by infectious disease,” he said.

European colonizers’ arrival in the late 1400s brought new diseases, including measles, that killed tens of millions of Indigenous people in North and South America by the early 1600s. Native Americans have also had high mortality rates in modern pandemics, including the 1918-20 Spanish flu and COVID-19.

The Great Plains Tribal Leaders’ Health Board reacted quickly when measles cases began showing up near its headquarters in South Dakota this year. Nebraska health officials announced in late May that a child had measles in a rural part of the state, close to the Pine Ridge Indian Reservation. Then, four people from the Rapid City area got sick later that month and into the middle of June.

“Our phones really rang off the hook” once that news came out, said Darren Crowe, a vice president at the board’s Oyate Health Center in Rapid City. He said parents wanted to know if their children were up to date on their measles vaccines.

Crowe said the health board ordered extra masks, created a measles command team that meets daily, and called parents when its online database showed their children needed a shot.

Brown praised that approach.

“It takes a concerted outreach effort that goes individual to individual,” he said, adding that his organization helped the Mississippi Band of Choctaw Indians and the Alabama-Coushatta Tribe of Texas with similar efforts.

Brown said reaching specific families can be a challenge in some low-income Native American communities, where many people’s phone numbers frequently change since they use temporary prepaid plans.

Once a health worker reaches a parent, Brown said, they should listen and ask questions before sharing the importance of the vaccine against measles, mumps, and rubella.

“Rather than trying to preach to somebody and beat them over the head with data or whatever to convince them that this is what they need to do, you start out by finding out where they are,” he said. “So, ‘Tell me about your experience with vaccination. Tell me what you know about vaccination.’”

Most people agree to immunize their children when presented with helpful information in a nonjudgmental way, Brown said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

RAPID CITY, S.D. — Cassandra Palmier had been meaning to get her son the second and final dose of the measles vaccine. But car problems made it difficult to get to the doctor.

So she pounced on the opportunity to get him vaccinated after learning that a mobile clinic would be visiting her neighborhood.

“I was definitely concerned about the epidemic and the measles,” Palmier, a member of the Oglala Sioux Tribe, said at the June event. “I wanted to do my part.”

So did her son, Makaito Cuny.

“I’m not going to be scared,” the 5-year-old announced as he walked onto the bus containing the clinic and hopped into an exam chair.

Makaito sat still as a nurse gave him the shot in his arm. “I did it!” he said while smiling at his mother.

The vaccine clinic was hosted by the Great Plains Tribal Leaders’ Health Board, which serves tribes across Iowa, Nebraska, and the Dakotas. It’s one way Native American tribes and organizations are responding to concerns about low measles vaccination rates and patients’ difficulty accessing health care as the disease spreads across the country.

Meghan O’Connell, the board’s chief public health officer, said it is also working with tribes that want to host vaccine clinics.

Elsewhere, tribal health organizations have launched social media campaigns, are making sure health providers are vaccinated, and are reaching out to the parents of unvaccinated children.

This spring, Project ECHO at the University of New Mexico hosted an online video series about measles aimed at health care professionals and organizations that serve Native American communities. The presenters outlined the basics of measles diagnosis and treatment, discussed culturally relevant communication strategies, and shared how tribes are responding to the outbreak.

Participants also strategized about ways to improve vaccination rates, said Harry Brown, a physician and an epidemiologist for the United South and Eastern Tribes, a nonprofit that works with 33 tribes in the Atlantic Coast and Southeast regions.

“It’s a pretty hot topic right now in Indian Country and I think a lot of people are being proactive,” he said.

Measles can survive for up to two hours in the air in a space where an infected person has been, sickening up to 90% of people who aren’t vaccinated, according to the Centers for Disease Control and Prevention.

The U.S. has had 1,319 confirmed cases of measles this year as of July 23, according to the CDC. It’s the largest outbreak in the U.S. since 1992. Ninety-two percent of the 2025 cases involve unvaccinated patients or people with an unknown vaccination status. Three people had died in the U.S. and 165 had been hospitalized as of July 23.

O’Connell said data on Native Americans’ vaccination rates is imperfect but that it suggests a lower percentage of them have received measles shots than the overall U.S. population.

The limited national data on measles vaccination rates for Native Americans is based on small surveys of people who self-identify as Native American. Some show that Native Americans have slightly lower measles vaccination rates, while others show significant gaps.

Data from some states, including South Dakota and Montana, shows that Native Americans are less likely than white children to be vaccinated on schedule.

The national measles vaccination rate is significantly lower for Native Americans who use the mostly rural Indian Health Service. About 76% of children 16 to 27 months old had gotten the first shot, according to data collected by the agency during recent patient visits at 156 clinics. That’s a 10-percentage-point drop from 10 years ago.

But the IHS data shows that its patients are at least as likely as other children to have received both recommended measles shots by the time they’re 17. O’Connell said it’s unclear if currently unvaccinated patients will continue the trend of eventually getting up to date on their shots or if they will remain unvaccinated.

The immunization rate is probably higher for older children since schools require students to get vaccinated unless they have an exemption, Brown said. He said it’s important that parents get their children vaccinated on time, when they’re young and more at risk of being hospitalized or dying from the disease.

Native Americans may have lower vaccination rates due to the challenges they face in accessing shots and other health care, O’Connell said. Those on rural reservations may be an hour or more from a clinic. Or, like Palmier, they may not have reliable transportation.

Another reason, O’Connell said, is that some Native Americans distrust the Indian Health Service, which is chronically underfunded and understaffed. If the only nearby health care facility is run by the agency, patients may delay or skip care.

O’Connell and Brown said vaccine skepticism and mistrust of the entire health care system are growing in Native American communities, as has occurred elsewhere nationwide.

“Prior to social media, I think our population was pretty trustful of childhood vaccination. And American Indians have a long history of being severely impacted by infectious disease,” he said.

European colonizers’ arrival in the late 1400s brought new diseases, including measles, that killed tens of millions of Indigenous people in North and South America by the early 1600s. Native Americans have also had high mortality rates in modern pandemics, including the 1918-20 Spanish flu and COVID-19.

The Great Plains Tribal Leaders’ Health Board reacted quickly when measles cases began showing up near its headquarters in South Dakota this year. Nebraska health officials announced in late May that a child had measles in a rural part of the state, close to the Pine Ridge Indian Reservation. Then, four people from the Rapid City area got sick later that month and into the middle of June.

“Our phones really rang off the hook” once that news came out, said Darren Crowe, a vice president at the board’s Oyate Health Center in Rapid City. He said parents wanted to know if their children were up to date on their measles vaccines.

Crowe said the health board ordered extra masks, created a measles command team that meets daily, and called parents when its online database showed their children needed a shot.

Brown praised that approach.

“It takes a concerted outreach effort that goes individual to individual,” he said, adding that his organization helped the Mississippi Band of Choctaw Indians and the Alabama-Coushatta Tribe of Texas with similar efforts.

Brown said reaching specific families can be a challenge in some low-income Native American communities, where many people’s phone numbers frequently change since they use temporary prepaid plans.

Once a health worker reaches a parent, Brown said, they should listen and ask questions before sharing the importance of the vaccine against measles, mumps, and rubella.

“Rather than trying to preach to somebody and beat them over the head with data or whatever to convince them that this is what they need to do, you start out by finding out where they are,” he said. “So, ‘Tell me about your experience with vaccination. Tell me what you know about vaccination.’”

Most people agree to immunize their children when presented with helpful information in a nonjudgmental way, Brown said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

RAPID CITY, S.D. — Cassandra Palmier had been meaning to get her son the second and final dose of the measles vaccine. But car problems made it difficult to get to the doctor.

So she pounced on the opportunity to get him vaccinated after learning that a mobile clinic would be visiting her neighborhood.

“I was definitely concerned about the epidemic and the measles,” Palmier, a member of the Oglala Sioux Tribe, said at the June event. “I wanted to do my part.”

So did her son, Makaito Cuny.

“I’m not going to be scared,” the 5-year-old announced as he walked onto the bus containing the clinic and hopped into an exam chair.

Makaito sat still as a nurse gave him the shot in his arm. “I did it!” he said while smiling at his mother.

The vaccine clinic was hosted by the Great Plains Tribal Leaders’ Health Board, which serves tribes across Iowa, Nebraska, and the Dakotas. It’s one way Native American tribes and organizations are responding to concerns about low measles vaccination rates and patients’ difficulty accessing health care as the disease spreads across the country.

Meghan O’Connell, the board’s chief public health officer, said it is also working with tribes that want to host vaccine clinics.

Elsewhere, tribal health organizations have launched social media campaigns, are making sure health providers are vaccinated, and are reaching out to the parents of unvaccinated children.

This spring, Project ECHO at the University of New Mexico hosted an online video series about measles aimed at health care professionals and organizations that serve Native American communities. The presenters outlined the basics of measles diagnosis and treatment, discussed culturally relevant communication strategies, and shared how tribes are responding to the outbreak.

Participants also strategized about ways to improve vaccination rates, said Harry Brown, a physician and an epidemiologist for the United South and Eastern Tribes, a nonprofit that works with 33 tribes in the Atlantic Coast and Southeast regions.

“It’s a pretty hot topic right now in Indian Country and I think a lot of people are being proactive,” he said.

Measles can survive for up to two hours in the air in a space where an infected person has been, sickening up to 90% of people who aren’t vaccinated, according to the Centers for Disease Control and Prevention.

The U.S. has had 1,319 confirmed cases of measles this year as of July 23, according to the CDC. It’s the largest outbreak in the U.S. since 1992. Ninety-two percent of the 2025 cases involve unvaccinated patients or people with an unknown vaccination status. Three people had died in the U.S. and 165 had been hospitalized as of July 23.

O’Connell said data on Native Americans’ vaccination rates is imperfect but that it suggests a lower percentage of them have received measles shots than the overall U.S. population.

The limited national data on measles vaccination rates for Native Americans is based on small surveys of people who self-identify as Native American. Some show that Native Americans have slightly lower measles vaccination rates, while others show significant gaps.

Data from some states, including South Dakota and Montana, shows that Native Americans are less likely than white children to be vaccinated on schedule.

The national measles vaccination rate is significantly lower for Native Americans who use the mostly rural Indian Health Service. About 76% of children 16 to 27 months old had gotten the first shot, according to data collected by the agency during recent patient visits at 156 clinics. That’s a 10-percentage-point drop from 10 years ago.

But the IHS data shows that its patients are at least as likely as other children to have received both recommended measles shots by the time they’re 17. O’Connell said it’s unclear if currently unvaccinated patients will continue the trend of eventually getting up to date on their shots or if they will remain unvaccinated.

The immunization rate is probably higher for older children since schools require students to get vaccinated unless they have an exemption, Brown said. He said it’s important that parents get their children vaccinated on time, when they’re young and more at risk of being hospitalized or dying from the disease.

Native Americans may have lower vaccination rates due to the challenges they face in accessing shots and other health care, O’Connell said. Those on rural reservations may be an hour or more from a clinic. Or, like Palmier, they may not have reliable transportation.

Another reason, O’Connell said, is that some Native Americans distrust the Indian Health Service, which is chronically underfunded and understaffed. If the only nearby health care facility is run by the agency, patients may delay or skip care.

O’Connell and Brown said vaccine skepticism and mistrust of the entire health care system are growing in Native American communities, as has occurred elsewhere nationwide.

“Prior to social media, I think our population was pretty trustful of childhood vaccination. And American Indians have a long history of being severely impacted by infectious disease,” he said.

European colonizers’ arrival in the late 1400s brought new diseases, including measles, that killed tens of millions of Indigenous people in North and South America by the early 1600s. Native Americans have also had high mortality rates in modern pandemics, including the 1918-20 Spanish flu and COVID-19.

The Great Plains Tribal Leaders’ Health Board reacted quickly when measles cases began showing up near its headquarters in South Dakota this year. Nebraska health officials announced in late May that a child had measles in a rural part of the state, close to the Pine Ridge Indian Reservation. Then, four people from the Rapid City area got sick later that month and into the middle of June.

“Our phones really rang off the hook” once that news came out, said Darren Crowe, a vice president at the board’s Oyate Health Center in Rapid City. He said parents wanted to know if their children were up to date on their measles vaccines.

Crowe said the health board ordered extra masks, created a measles command team that meets daily, and called parents when its online database showed their children needed a shot.

Brown praised that approach.

“It takes a concerted outreach effort that goes individual to individual,” he said, adding that his organization helped the Mississippi Band of Choctaw Indians and the Alabama-Coushatta Tribe of Texas with similar efforts.

Brown said reaching specific families can be a challenge in some low-income Native American communities, where many people’s phone numbers frequently change since they use temporary prepaid plans.

Once a health worker reaches a parent, Brown said, they should listen and ask questions before sharing the importance of the vaccine against measles, mumps, and rubella.

“Rather than trying to preach to somebody and beat them over the head with data or whatever to convince them that this is what they need to do, you start out by finding out where they are,” he said. “So, ‘Tell me about your experience with vaccination. Tell me what you know about vaccination.’”

Most people agree to immunize their children when presented with helpful information in a nonjudgmental way, Brown said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

TOPLINE:

Bone health management for older women with breast cancer receiving aromatase inhibitors (AIs) varied substantially across 5 UK hospitals. Despite the higher risk for fractures, women aged > 80 years were less likely to receive DEXA scans or bisphosphonates, highlighting the urgent need for standardised bone monitoring and treatment in frail older patients.

METHODOLOGY:

• This secondary analysis of the multicentre Age Gap study included 529 women (age ≥ 70 years) with oestrogen receptor-positive early breast cancer who received AIs, either as primary or adjuvant treatment, at five hospitals in the UK.
• Researchers collected comprehensive data including the type of endocrine therapy, DEXA scan results, bisphosphonate usage, calcium and vitamin D supplementation, and the incidence of fractures during or after AI therapy.
• Frailty was assessed using a modified Rockwood Frailty Index, with scores being calculated across 75 variables to categorise patients as robust (< 0.08), prefrail (0.08-0.25), or frail (> 0.25).

TAKEAWAY:

• Overall, 67% of patients had baseline DEXA scans. Of these, 42% were osteopenic and 18% osteoporotic. Scans were more common in 70- to 79-year-olds than in those aged ≥ 80 years and in women undergoing surgery than in those undergoing primary endocrine therapy, with marked variation across centres (P < .001 for all).
• Among patients receiving AI therapy, 43% were prescribed bisphosphonates, especially those who had surgery (hazard ratio [HR], 1.36; P = .04) and those aged 70-79 years (HR, 1.31; P = .02); 33% had vitamin D plus calcium along with bisphosphonates.
• During follow-up, 23% of patients had fractures, with significant variation across centres (P = .02), and 38% of these patients had received prior bisphosphonates.
• Although 94% of patients were frail or prefrail, frailty did not correlate with baseline hip (P = .10) or spine (P = .89) T scores. Bisphosphonates plus AIs were prescribed in 70% of nonfrail participants vs 43% of prefrail and 47% of frail participants (P = .02).

IN PRACTICE:

“Patient’s age and general health influence bone health decision making, with older and frailer patients often receiving non-standard care. Despite national and international recommendations, there is still wide variation in bone health management, highlighting the need for further education and standardised bone health care in older women with breast cancer,” the authors wrote.

SOURCE:

This study was led by Elisavet Theodoulou, University of Sheffield, Sheffield, England. It was published online, in the Journal of Geriatric Oncology.

LIMITATIONS:

The study’s inclusion of only 5 hospital sites limited the ability to draw broader conclusions about bone health management practices across a wider range of centres. Additionally, the interpretation of the results was complicated by the introduction of adjuvant bisphosphonates during the study period, making the cohort unstable in terms of bisphosphonate usage indications.

DISCLOSURES:

The Age Gap study was supported by the National Institute for Health and Care Research Programme Grants for Applied Research. The authors declared having no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

Bone health management for older women with breast cancer receiving aromatase inhibitors (AIs) varied substantially across 5 UK hospitals. Despite the higher risk for fractures, women aged > 80 years were less likely to receive DEXA scans or bisphosphonates, highlighting the urgent need for standardised bone monitoring and treatment in frail older patients.

METHODOLOGY:

• This secondary analysis of the multicentre Age Gap study included 529 women (age ≥ 70 years) with oestrogen receptor-positive early breast cancer who received AIs, either as primary or adjuvant treatment, at five hospitals in the UK.
• Researchers collected comprehensive data including the type of endocrine therapy, DEXA scan results, bisphosphonate usage, calcium and vitamin D supplementation, and the incidence of fractures during or after AI therapy.
• Frailty was assessed using a modified Rockwood Frailty Index, with scores being calculated across 75 variables to categorise patients as robust (< 0.08), prefrail (0.08-0.25), or frail (> 0.25).

TAKEAWAY:

• Overall, 67% of patients had baseline DEXA scans. Of these, 42% were osteopenic and 18% osteoporotic. Scans were more common in 70- to 79-year-olds than in those aged ≥ 80 years and in women undergoing surgery than in those undergoing primary endocrine therapy, with marked variation across centres (P < .001 for all).
• Among patients receiving AI therapy, 43% were prescribed bisphosphonates, especially those who had surgery (hazard ratio [HR], 1.36; P = .04) and those aged 70-79 years (HR, 1.31; P = .02); 33% had vitamin D plus calcium along with bisphosphonates.
• During follow-up, 23% of patients had fractures, with significant variation across centres (P = .02), and 38% of these patients had received prior bisphosphonates.
• Although 94% of patients were frail or prefrail, frailty did not correlate with baseline hip (P = .10) or spine (P = .89) T scores. Bisphosphonates plus AIs were prescribed in 70% of nonfrail participants vs 43% of prefrail and 47% of frail participants (P = .02).

IN PRACTICE:

“Patient’s age and general health influence bone health decision making, with older and frailer patients often receiving non-standard care. Despite national and international recommendations, there is still wide variation in bone health management, highlighting the need for further education and standardised bone health care in older women with breast cancer,” the authors wrote.

SOURCE:

This study was led by Elisavet Theodoulou, University of Sheffield, Sheffield, England. It was published online, in the Journal of Geriatric Oncology.

LIMITATIONS:

The study’s inclusion of only 5 hospital sites limited the ability to draw broader conclusions about bone health management practices across a wider range of centres. Additionally, the interpretation of the results was complicated by the introduction of adjuvant bisphosphonates during the study period, making the cohort unstable in terms of bisphosphonate usage indications.

DISCLOSURES:

The Age Gap study was supported by the National Institute for Health and Care Research Programme Grants for Applied Research. The authors declared having no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

Bone health management for older women with breast cancer receiving aromatase inhibitors (AIs) varied substantially across 5 UK hospitals. Despite the higher risk for fractures, women aged > 80 years were less likely to receive DEXA scans or bisphosphonates, highlighting the urgent need for standardised bone monitoring and treatment in frail older patients.

METHODOLOGY:

• This secondary analysis of the multicentre Age Gap study included 529 women (age ≥ 70 years) with oestrogen receptor-positive early breast cancer who received AIs, either as primary or adjuvant treatment, at five hospitals in the UK.
• Researchers collected comprehensive data including the type of endocrine therapy, DEXA scan results, bisphosphonate usage, calcium and vitamin D supplementation, and the incidence of fractures during or after AI therapy.
• Frailty was assessed using a modified Rockwood Frailty Index, with scores being calculated across 75 variables to categorise patients as robust (< 0.08), prefrail (0.08-0.25), or frail (> 0.25).

TAKEAWAY:

• Overall, 67% of patients had baseline DEXA scans. Of these, 42% were osteopenic and 18% osteoporotic. Scans were more common in 70- to 79-year-olds than in those aged ≥ 80 years and in women undergoing surgery than in those undergoing primary endocrine therapy, with marked variation across centres (P < .001 for all).
• Among patients receiving AI therapy, 43% were prescribed bisphosphonates, especially those who had surgery (hazard ratio [HR], 1.36; P = .04) and those aged 70-79 years (HR, 1.31; P = .02); 33% had vitamin D plus calcium along with bisphosphonates.
• During follow-up, 23% of patients had fractures, with significant variation across centres (P = .02), and 38% of these patients had received prior bisphosphonates.
• Although 94% of patients were frail or prefrail, frailty did not correlate with baseline hip (P = .10) or spine (P = .89) T scores. Bisphosphonates plus AIs were prescribed in 70% of nonfrail participants vs 43% of prefrail and 47% of frail participants (P = .02).

IN PRACTICE:

“Patient’s age and general health influence bone health decision making, with older and frailer patients often receiving non-standard care. Despite national and international recommendations, there is still wide variation in bone health management, highlighting the need for further education and standardised bone health care in older women with breast cancer,” the authors wrote.

SOURCE:

This study was led by Elisavet Theodoulou, University of Sheffield, Sheffield, England. It was published online, in the Journal of Geriatric Oncology.

LIMITATIONS:

The study’s inclusion of only 5 hospital sites limited the ability to draw broader conclusions about bone health management practices across a wider range of centres. Additionally, the interpretation of the results was complicated by the introduction of adjuvant bisphosphonates during the study period, making the cohort unstable in terms of bisphosphonate usage indications.

DISCLOSURES:

The Age Gap study was supported by the National Institute for Health and Care Research Programme Grants for Applied Research. The authors declared having no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.