How long before knee surgery should dapagliflozin (Farxiga) and tirzepatide (Mounjaro) be discontinued?

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Last updated: September 25, 2026 • View editorial policy

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Preoperative Discontinuation of Farxiga and Mounjaro Before Knee Surgery

Stop Farxiga (dapagliflozin) at least 3 days before knee surgery, and stop Mounjaro (tirzepatide) on the day of surgery (though ideally 1 week prior for GLP-1 agonists given gastric emptying concerns).

Farxiga (Dapagliflozin) - SGLT2 Inhibitor

Discontinuation Timeline

  • Withhold for at least 3 days prior to surgery 1
  • This recommendation comes directly from the FDA label and is echoed in the most recent 2025 American Diabetes Association guidelines 2, 3

Critical Rationale

The 3-4 day discontinuation period is essential because:

  • Ketoacidosis risk: SGLT2 inhibitors can cause life-threatening euglycemic diabetic ketoacidosis (DKA) in the perioperative period, even in non-diabetic patients 4
  • Surgical stress, fasting, and volume depletion are precipitating factors
  • Urinary glucose excretion persists for 3 days after stopping, but ketoacidosis has been reported lasting up to 2 weeks post-discontinuation 1
  • A case report documented postoperative ketoacidosis with hypoglycemia in an 83-year-old non-diabetic woman taking dapagliflozin for heart failure who took it on the day of surgery 4

Important Caveat

This applies regardless of the indication - whether prescribed for diabetes, heart failure, or chronic kidney disease 4, 5. The ketoacidosis risk exists across all indications.

Mounjaro (Tirzepatide) - GLP-1/GIP Receptor Agonist

Discontinuation Timeline

The evidence for GLP-1 receptor agonists is less definitive, but critical considerations exist:

  • ADA guidelines state: "There are little data on the safe use and/or influence of GLP-1 receptor agonists on glycemia and delayed gastric emptying in the perioperative period" 3
  • Practical recommendation: Hold on the day of surgery at minimum, but ideally discontinue 1 week prior given the weekly dosing schedule and concerns about delayed gastric emptying 6

Critical Rationale

  • Aspiration risk: GLP-1 agonists cause delayed gastric emptying, increasing risk of regurgitation and aspiration during general anesthesia or deep sedation 6
  • Tirzepatide has a weekly dosing schedule, so stopping "the day of surgery" effectively means the patient won't take their weekly dose
  • Given the half-life and gastric effects, a full week without dosing provides the safest margin

Perioperative Management Algorithm

3-4 Days Before Surgery (Minimum)

  • Stop Farxiga - non-negotiable for all indications
  • Document discontinuation in medical record

1 Week Before Surgery (Ideal)

  • Stop Mounjaro - skip the weekly dose that would fall within 7 days of surgery
  • Consider NPO precautions as if patient has full stomach if taken closer to surgery date

Day of Surgery

  • Confirm both medications were held appropriately
  • Monitor for signs of ketoacidosis regardless of blood glucose levels (nausea, vomiting, abdominal pain, shortness of breath) 1
  • Target perioperative glucose 100-180 mg/dL 2, 3
  • Do not rely on CGM alone for intraoperative glucose monitoring 2

Postoperative Resumption

  • Resume only when: Patient is clinically stable, has resumed oral intake, and is no longer at risk for prolonged fasting 1
  • Continue monitoring for ketoacidosis signs for several days after resuming SGLT2 inhibitors

Common Pitfalls to Avoid

  1. Don't assume heart failure indication changes SGLT2 inhibitor management - the ketoacidosis risk exists regardless of why the patient takes it 4

  2. Don't restart medications too early - wait until patient has stable oral intake and is past the acute surgical stress period 1

  3. Don't ignore normal glucose levels - euglycemic DKA can occur with glucose <250 mg/dL; assess for ketones if metabolic acidosis symptoms present 1

  4. Don't forget aspiration precautions - if Mounjaro was taken within a week of surgery, treat as delayed gastric emptying risk 6

References

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