Preoperative SGLT2 Inhibitor Use Is Associated With Reduced 90-Day Complications and Lower Prolonged Opioid Use After Posterior Lumbar Fusion

Study Design: Retrospective propensity-matched cohort study using a national all-payer claims database. Objective: To evaluate the association between preoperative sodium-glucose cotransporter-2 inhibitor (SGLT2) use and 90-day complications, two-year reoperations, total postoperative cost, and prolonged opioid use after primary one- to three-level posterior lumbar fusion (PLF). Summary of Background Data: Diabetes is associated with worse outcomes after spinal fusion, including pseudoarthrosis. SGLT2 use is expanding rapidly, but its perioperative profile in spine surgery is poorly characterized, with concern for euglycemic diabetic ketoacidosis (DKA) balanced against possible anti-inflammatory and cardiorenal benefits. Materials and Methods: The PearlDiver Mariner 170 data set was queried for patients undergoing primary one- to three-level PLF (2010–2023). SGLT2 users (≥1 fill within 6 mo preoperatively) were propensity-matched 3:1 to nonusers on demographics and comorbidities. Univariate analyses compared 90-day complications, two-year outcomes, cost, and prolonged opioid use; SGLT2 users were stratified by duration of use. Results: After matching (>6200 patients), groups were similar across demographics and comorbidities, with no significant differences in age, sex, Charlson Comorbidity Index score, or rates of obesity, tobacco use, alcohol disorders, anxiety/depression, diabetes, hypertension, osteoporosis, cardiac disorders, thyroid disorders, rheumatologic disease, or chronic kidney disease. At 90 days postoperatively, patients prescribed SGLT2 inhibitors had lower rates of readmission (7.4% vs. 9.2%; P =0.034) and pneumonia (1.2% vs . 2.3%; P =0.010) compared with patients not prescribed SGLT2 inhibitors, with no significant differences in other outcomes. Over two years postoperatively, no significant differences in pseudoarthrosis or reoperation rates were observed. SGLT2 users had higher total cost ($42,464 vs . $35,242; P <0.001) and lower prolonged opioid use (46.0% vs. 52.0%; P <0.001), which decreased with longer use (long-term 39.0% vs . new 51.1%; P <0.001). Conclusion: Preoperative SGLT2 use was not associated with increased surgical risk after PLF and may be associated with favorable perioperative and opioid outcomes.