Preoperative GLP-1 agonists were not linked to more aspiration

Design

Observational, 1:1 propensity-score-matched analysis of an electronic-health-record network

Population

Adults with type 2 diabetes having anaesthesia, on a GLP-1 agonist vs metformin, SGLT2 inhibitor or DPP-4 inhibitor

Primary outcome

14-day postoperative mortality, aspiration pneumonitis and other morbidity

Effect

No excess aspiration; mortality 0.98% vs 2.20% vs metformin (risk ratio 0.44, 0.31 to 0.64)

Whether to hold GLP-1 receptor agonists before surgery, because of delayed gastric emptying and aspiration risk, is one of the live questions in perioperative medicine. This observational analysis used a large electronic-health-record network, with data before the 2023 ASA guidance to hold these drugs, propensity-matching patients with type 2 diabetes on a GLP-1 agonist against those on metformin, an SGLT2 inhibitor, or a DPP-4 inhibitor.

Preoperative GLP-1 agonist use was not associated with increased aspiration pneumonitis against any comparator. It was linked to lower 14-day mortality than metformin (0.98% vs 2.20%; risk ratio 0.44, 95% CI 0.31 to 0.64) and than DPP-4 inhibitors (1.84% vs 2.89%; risk ratio 0.63, 0.45 to 0.89), with less bacterial pneumonia versus DPP-4 inhibitors.

The finding is reassuring but observational, with confounding by indication a real limitation. It supports not over-restricting these drugs, but it is not grounds to discard current fasting and risk-assessment guidance; prospective trials are needed before practice changes.

• Observational, propensity-matched analysis of surgical patients with type 2 diabetes, before the 2023 ASA hold guidance.
• No increased aspiration pneumonitis with preoperative GLP-1 agonist use against any comparator.
• Lower 14-day mortality than metformin (0.98% vs 2.20%; risk ratio 0.44, 95% CI 0.31 to 0.64).
• Lower mortality and bacterial pneumonia than DPP-4 inhibitors.
• Reassuring but observational; do not abandon current fasting and risk-assessment guidance on this alone.

Why it matters

It speaks directly to the current debate on holding GLP-1 agonists before surgery, pushing against blanket restriction without settling it.

Don't overread it

This was observational with likely confounding by indication; the apparent mortality benefit may reflect who takes these drugs rather than the drugs themselves.

The statistics, in plain English

A mortality risk ratio of 0.44 looks large, but in an observational study the sicker or healthier patients may cluster by drug; the absence of an aspiration signal is reassuring yet cannot carry the certainty of a randomised trial.

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