Preoperative Medication Management
Stop Jardiance (empagliflozin) the day before surgery and continue Lantus (insulin glargine) and lisinopril through the perioperative period with appropriate dose adjustments.
Jardiance (Empagliflozin) - SGLT2 Inhibitor
Jardiance must be stopped the day before and the day of the procedure 1. This means:
- If taking morning doses and surgery is scheduled in the morning: minimum 48-hour gap
- If taking morning doses and surgery is in the afternoon: over 52-hour gap
- If taking evening doses: minimum 36-hour gap
Rationale for Stopping Jardiance
The primary concern is euglycemic diabetic ketoacidosis (EDKA), which can occur even with normal blood glucose levels 1, 2. The risk of perioperative DKA is significantly higher in patients taking SGLT2 inhibitors (1.02 vs 0.69 per 1000 patients, OR 1.48) 1. Cases of postoperative ketoacidosis have been reported even when patients withheld SGLT2 inhibitors for >72 hours, emphasizing that risk exists on a continuum 1, 2.
Critical Mitigation Strategies While Off Jardiance
- Ensure adequate hydration
- Avoid prolonged fasting periods
- Consider glucose-containing IV fluids if prolonged fasting is unavoidable
- Monitor glucose and ketones appropriately 1
When to Restart Jardiance
- Day surgery patients: Restart once eating and drinking normally (usually 24-48 hours post-surgery)
- Inpatient surgery: Restart once eating/drinking normally AND capillary ketones <0.6 mmol/L 1
Lantus (Insulin Glargine) - Continue with Adjustments
Do not stop basal insulin prior to surgery. Insulin glargine should be continued perioperatively, though the dose may need adjustment based on:
- Duration of fasting
- Surgical stress response
- Blood glucose monitoring results
Stopping basal insulin increases the risk of hyperglycemia and ketoacidosis, particularly when the SGLT2 inhibitor is already being held. The patient will need insulin coverage to prevent metabolic decompensation.
Lisinopril - Continue in Most Cases
Lisinopril can generally be continued through surgery, though this decision depends on:
- Type and duration of surgery
- Patient's cardiovascular status
- Risk of hypotension during anesthesia
There is no absolute requirement to stop ACE inhibitors preoperatively for most procedures. If there are concerns about intraoperative hypotension (major surgery, significant fluid shifts expected), discuss with the anesthesia team about holding the morning dose on the day of surgery.
Common Pitfalls to Avoid
- Do not stop all diabetes medications: This creates dangerous hyperglycemia, especially when stopping the SGLT2 inhibitor already removes glucose control
- Do not assume normal glucose means no ketoacidosis: EDKA is euglycemic by definition 1, 2
- Do not restart Jardiance too early: Wait until the patient is eating/drinking normally and ketones are cleared 1
- Do not allow prolonged preoperative fasting: This significantly increases ketoacidosis risk in patients who were on SGLT2 inhibitors 1