GLP-1 drugs lowered stroke risk

In Swedish routine care, GLP-1 receptor agonists were associated with fewer strokes in adults with type 2 diabetes.
*Nationwide longitudinal cohort study; Level 2b (OCEBM).

Citation

Mavridis A, Abzhandadze T, Buvarp D, et al. eClinicalMedicine. 2026;100:104220. doi:10.1016/j.eclinm.2026.104220

Background

Type 2 diabetes increases stroke risk. Prior trials generally suggest stroke benefit with GLP-1 receptor agonists, but neutral stroke findings for SGLT2 and DPP-4 inhibitors; real-world studies have been inconsistent.

Patients

171,917 Swedish adults with type 2 diabetes first registered from 2013 to 2019. Excluded: prior stroke, insufficient data for missing-value methods, or no observable follow-up.

Intervention

Time-updated use of SGLT2 inhibitors, GLP-1 receptor agonists, or DPP-4 inhibitors.

Control

Non-use of the drug class being analyzed.

Outcome

Primary: ischemic stroke. Secondary: hemorrhagic stroke and total stroke.

Follow-up Period

Mean 3.0 years; maximum 7 years.

Results

Drug class Outcome Hazard ratio
GLP-1 receptor agonists Ischemic stroke (primary) HR 0.46 (95% CI 0.29 to 0.72)
GLP-1 receptor agonists Total stroke HR 0.51 (95% CI 0.33 to 0.79)

GLP-1 = glucagon-like peptide-1; SGLT2 = sodium-glucose cotransporter 2; DPP-4 = dipeptidyl peptidase-4; HR = hazard ratio; CI = confidence interval.

SGLT2 inhibitors and DPP-4 inhibitors showed no significant association with ischemic, hemorrhagic, or total stroke. Hemorrhagic stroke results were imprecise. Analyses reflected observed treatment use over time, not randomized intention-to-treat. Total stroke findings were likely driven by ischemic stroke. Number needed to treat could not be reliably calculated from reported data.

Limitations

Observational design cannot prove causation. Missing data were substantial. Unmeasured confounding, prescription-use misclassification, and model assumptions may affect results. Swedish registry data may not generalize to all health systems.

Funding

Public and nonprofit Swedish funders; no funder role reported.

Clinical Application

For type 2 diabetes patients needing stroke-risk reduction, consider GLP-1 receptor agonists while preserving SGLT2 choices for kidney or heart failure benefits.