Perioperative Management of Entresto and Farxiga for Knee Surgery
Farxiga (dapagliflozin) should be stopped at least 3 days before knee surgery, while Entresto (sacubitril-valsartan) should generally be continued through the perioperative period unless the patient has decompensated heart failure or develops hypotension. 1
Farxiga (Dapagliflozin) - MUST STOP
The 2024 AHA/ACC Perioperative Guidelines provide a Class 1 recommendation to withhold SGLT2 inhibitors like Farxiga for 3-4 days before elective noncardiac surgery to reduce the risk of perioperative metabolic acidosis 1. Specifically:
- Dapagliflozin should be stopped ≥3 days before scheduled surgery
- This is a strong, evidence-based recommendation to prevent euglycemic diabetic ketoacidosis, a potentially life-threatening complication
- Resume postoperatively once the patient is stable, eating, and adequately hydrated
Entresto (Sacubitril-Valsartan) - CONTINUE
The same 2024 guidelines provide a Class 2a recommendation stating it is reasonable to continue guideline-directed medical therapy (GDMT) for heart failure—excluding SGLT2 inhibitors—in the perioperative period for patients with compensated heart failure 1.
Rationale for Continuation:
- Delaying resumption of RAAS inhibitors (which Entresto functions as) increases 30-day mortality risk 1
- Withdrawal of chronic antihypertensive medications can trigger postoperative hypertension, increasing risk of myocardial ischemia, acute heart failure decompensation, and cerebral ischemia 1
- Discontinuing Entresto leads to deterioration of left ventricular ejection fraction and worsening functional class, even when switched to conventional ACE inhibitors or ARBs 2
Important Caveats for Entresto:
Monitor closely for hypotension, especially during anesthetic induction. The FDA label warns that Entresto lowers blood pressure and may cause symptomatic hypotension, particularly in volume-depleted patients 3. If significant hypotension occurs:
- Adjust diuretic doses
- Treat volume depletion
- Consider temporary dose reduction (but avoid complete discontinuation)
- Use vasopressors if needed 3
Avoid if the patient has:
- Active decompensated heart failure (should optimize before elective surgery)
- History of angioedema with ACE inhibitors or ARBs 3
- Severe volume depletion that cannot be corrected preoperatively
Postoperative Management
- Resume Farxiga once the patient is eating, drinking, metabolically stable, and not at risk for volume depletion (typically 24-48 hours postoperatively)
- Continue Entresto throughout, but monitor blood pressure closely and adjust for hypotension as needed
- Restart chronically taken antihypertensive medications "as soon as clinically reasonable" to avoid complications from postoperative hypertension 1
Common Pitfall to Avoid
Do not stop all heart failure medications perioperatively out of excessive caution about hypotension. The evidence shows that continuing RAAS inhibitors like Entresto reduces mortality, while stopping them increases risk 1. The key is appropriate hemodynamic monitoring and management, not blanket discontinuation.