Should dapagliflozin (Farxiga) be held for a patient who is nil per os (NPO)?

Hold Farxiga for NPO Status

Yes, dapagliflozin (Farxiga) should be held when a patient is NPO, particularly if the NPO status is in preparation for surgery or a procedure. The 2024 AHA/ACC perioperative guidelines provide clear, specific timing recommendations for withholding SGLT2 inhibitors like dapagliflozin before surgical procedures 1.

Specific Timing for Holding Dapagliflozin

Dapagliflozin must be stopped at least 3 days (≥72 hours) before scheduled surgery 1. This is a Class 1 recommendation (meaning "should be done") with the primary goal of reducing the risk of perioperative metabolic acidosis, including life-threatening ketoacidosis.

Why This Matters: The Ketoacidosis Risk

The rationale for holding Farxiga during NPO status is critical to understand:

• SGLT2 inhibitors significantly increase the risk of ketoacidosis, which can be fatal 2
• NPO status is a precipitating condition for ketoacidosis because it represents reduced caloric intake and potential volume depletion 2
• Other precipitating factors that often accompany NPO status include: surgery, acute illness, volume depletion, and under-insulinization 2
• Ketoacidosis can occur even with normal or low blood glucose levels (euglycemic DKA), making it particularly dangerous and easy to miss 2
• Urinary glucose excretion persists for 3 days after discontinuing Farxiga, and there have been postmarketing reports of ketoacidosis lasting greater than 6 days and up to 2 weeks after SGLT2 inhibitor discontinuation 2

Clinical Algorithm for NPO Situations

For Scheduled Surgery/Procedures:

1. Stop dapagliflozin ≥3 days before the procedure 1
2. Monitor for signs of ketoacidosis if the patient develops symptoms (nausea, vomiting, abdominal pain, malaise, shortness of breath) 2
3. Resume dapagliflozin only when the patient is clinically stable and has resumed oral intake 2

For Acute NPO Status (Unplanned):

1. Withhold Farxiga immediately when NPO status begins, especially if accompanied by acute illness, volume depletion, or reduced caloric intake 2
2. Consider ketone monitoring in high-risk patients 2
3. Assess for ketoacidosis regardless of blood glucose levels if the patient develops concerning symptoms 2
4. Do not restart until oral intake resumes and the patient is clinically stable 2

Important Caveats

Volume depletion is a dual concern: SGLT2 inhibitors cause intravascular volume depletion, which can manifest as symptomatic hypotension or acute kidney injury 2. NPO status compounds this risk, making it even more critical to hold the medication.

Patient education is essential: All patients on Farxiga should be educated about the signs and symptoms of ketoacidosis (nausea, vomiting, abdominal pain, malaise, shortness of breath) and instructed to discontinue the medication and seek immediate medical attention if these occur 2.

The "old insulin hold" mistake doesn't apply here: While the outdated practice of holding all diabetes medications when NPO has been abandoned for insulin and most oral agents 3, SGLT2 inhibitors are the exception due to their unique mechanism and ketoacidosis risk 1, 2.