Many of the side effects of GLP-1 use are well known. Gastrointestinal (GI) issues, muscle loss, etc. They’ve been well researched. But a lesser-known result of the weight-loss drugs is gaining attention. And it would not please the etiquette police.

Chronic supragastric belching, characterized by frequent, persistent air intake and expulsion without reaching the stomach, can significantly impair a patient’s quality of life. While often overlooked, this condition is gaining clinical attention, particularly as primary care providers (PCPs) manage an increasing volume of GI complaints in patients using GLP-1 receptor agonists.

Carol S. Murakami, MD, of Kaiser Permanente South Bay in Harbor City, California, said data on belching among patients using GLP-1 receptor agonists remain limited, but one study of semaglutide reported belching in approximately 11% of participants. “If belching occurs 3 or more days a week for at least 3 months, it is considered abnormal and should prompt further evaluation,” she said.

However, a recent multicenter randomized controlled trial published in Clinical Gastroenterology and Hepatology offers a novel, low-risk behavioral intervention: structured singing therapy.

The study enrolled 72 adults with supragastric belching and compared structured singing therapy with diaphragmatic breathing, the current first-line behavioral approach.

Among the key findings:

• Greater symptom reduction: At 1 week, 72.2% of participants assigned to singing therapy achieved at least a 50% reduction in symptom severity, compared with 38.9% of those assigned to diaphragmatic breathing.
• Durability of response: Symptom improvement was maintained at the 1-month follow-up assessment.
• Acceptability and engagement: Participants described singing therapy as more acceptable and enjoyable than repetitive breathing exercises, indicating a potential advantage for adherence.

Haitao Shang, MD, one of the co-first authors of this study, and an associate chief physician specializing in functional GI disorders in China, said the findings support structured singing therapy as a clinical option for this patient population.

“Structured singing therapy outperforms the standard first-line diaphragmatic breathing approach in both short-term symptom relief and 1-month sustained benefits, while its enjoyable format drastically boosts patient adherence, especially for older adults and those with more severe symptoms who often struggle to stick to traditional behavioral treatments,” Shang said.

Murakami said the findings are clinically relevant despite important limitations.

“Even though the study was performed in China, the results of the study are intriguing and are very relevant to clinical practice in the US,” she said. She said both diaphragmatic breathing and singing therapy aim to retrain the diaphragm, but singing may offer an additional anxiolytic effect, whereas structured breathing exercises may be experienced and cause stress in some patients.

Murakami also cautioned that the trial had several limitations, including lack of standardized diagnostic testing before enrollment, use of a visual analogue scale that lacked formal validation, short follow-up, lack of blinding, and inclusion of only Chinese participants.

“Although the study is flawed, it lays the groundwork for future studies to validate singing therapy as a potentially more effective modality for the treatment of supragastric belching,” she said.

Clinical Relevance in Primary Care

For PCPs, distinguishing between behavioral supragastric belching and medication-related side effects is a common diagnostic challenge, particularly as more patients present with GI symptoms while taking GLP-1 receptor agonists.

Alexa Malchuk, MD, a family medicine physician in State College, Pennsylvania, said timing is an important clinical clue.

“Typically, belching as a medication side effect will start close to when the medication was started or the dose was increased,” she said. She added that it is “often is related to meal timing as well and can be associated with other symptoms like nausea and heartburn or indigestion.”

Diagnostic distinctions:

• Timing and context: Medication-induced belching may be related to initiation or dose escalation of a GLP-1 agonist, particularly when symptoms occur around meals and are accompanied by nausea, heartburn, or indigestion. Murakami said GI side effects are common in this population and said clinicians should obtain thorough psychiatric, GI, and family histories before initiating GLP-1 therapy.
• Behavioral red flags: Behavioral supragastric belching may be suggested when belching decreases with distraction but increases when attention is directed toward the symptom. Malchuk noted that it “may be associated with other anxiety disorders,” a finding that can help primary care clinicians decide when further evaluation is warranted. Murakami added that supragastric belching can still represent a behavioral disorder even after GLP-1 therapy begins, particularly in patients with preexisting depression, anxiety, or maladaptive coping.
• Referral threshold: If pathologic belching is suspected, Murakami said referral to gastroenterology is appropriate to determine whether symptoms reflect gastric or supragastric belching. In patients taking GLP-1 receptor agonists, clinicians may also need to assess overlapping gastroesophageal reflux disease or delayed gastric emptying.

Integrating Behavioral Interventions

While the Chinese study results are “intriguing and relevant,” incorporating singing therapy into a busy family medicine clinic may require careful framing and practical counseling. Malchuk said behavioral therapies that involve ancillary services, including “physical therapy, vocal/singing therapy, etc,” can be harder to implement because they require “time away from work or family, additional copayments/money and can take longer to see benefit.”

“Given the nature of the disorder, a multidisciplinary approach would be best, including family medicine, gastroenterology, behavioral therapy, and speech-language pathology,” Murakami said.

While PCPs can identify and initially manage these patients by treating comorbid conditions such as gastroesophageal reflux disease, she said gastroenterologists should be involved in diagnosis and treatment, including evaluation of reflux disease and gastroparesis.

Murakami said that a singing-based pathway could be feasible if gastroenterologists work closely with speech-language pathologists to learn diaphragmatic breathing and singing therapy techniques.

Malchuk is an educational consultant for Exact Sciences. Murakami and Shang reported no relevant disclosures.