Preoperative GLP-1 receptor agonist use was not linked to more aspiration in a large matched analysis

Design

Retrospective propensity-matched cohort (electronic health record network)

Population

Adults with type 2 diabetes having anaesthesia, 2013-2023

Primary outcome

14-day mortality, aspiration and other postoperative complications

Effect

Mortality vs metformin RR 0.44 (0.31-0.64); no increase in aspiration pneumonitis

Using a large electronic health record network from 2013 to June 2023, before the 2023 American Society of Anesthesiologists advice to hold these drugs, investigators propensity-matched adults with type 2 diabetes having anaesthesia who were taking a GLP-1 receptor agonist against those on metformin, SGLT2 inhibitors or DPP-4 inhibitors (Anesthesiology, 25 September 2026).

Compared with metformin, GLP-1 receptor agonist use was associated with lower 14-day mortality (0.98% vs 2.20%; RR 0.44, 95% CI 0.31-0.64). Compared with DPP-4 inhibitors, mortality (RR 0.63) and bacterial pneumonia (RR 0.47) were lower. There was no increase in aspiration pneumonitis against any comparator.

The aspiration finding is reassuring but cannot by itself overturn current fasting and gastric-emptying guidance; the mortality differences are almost certainly influenced by who is prescribed which drug.

• Continue to follow your current institutional or society guidance on GLP-1 receptor agonists before surgery.
• Ask about gastrointestinal symptoms on the day of surgery, which matter more than the drug alone.
• Consider gastric ultrasound where symptoms or dose escalation raise concern.
• Do not cite this study as evidence that GLP-1 drugs lower surgical mortality.

Why it matters

It adds large-scale data to a question where most guidance rests on case reports and gastric-emptying physiology.

Don't overread it

Associations with lower mortality are likely confounded by prescribing patterns and cannot show the drug protected patients.

The statistics, in plain English

Propensity matching balances measured factors only. A risk ratio of 0.44 for mortality is larger than any plausible drug effect over 14 days, a hint that unmeasured differences remain.

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