From the Guidelines
SGLT2 inhibitors should be discontinued at least 3-4 days before elective surgery and not restarted until the patient is eating and drinking normally postoperatively. This recommendation is primarily due to the risk of euglycemic diabetic ketoacidosis (euDKA) in the perioperative period, which can be difficult to diagnose as blood glucose levels may remain near normal 1. The risk of euDKA increases during periods of fasting, stress, and reduced carbohydrate intake—all common during the perioperative period. Additionally, SGLT2 inhibitors have diuretic effects that could potentially complicate fluid management during surgery.
Some key points to consider in the management of SGLT2 inhibitors in the perioperative period include:
- The risk of peri-operative ketoacidosis and mitigation strategies should be discussed with the patient using a shared decision-making approach 1.
- Patients and clinicians should adhere to recommended fasting guidelines and avoid prolonged starvation times.
- For patients discharged from hospital on the day of surgery, SGLT2 inhibitors should be restarted once eating and drinking normally (usually 24–48 h after surgery) 1.
- For patients staying in hospital after surgery, consider restarting SGLT2 inhibitors once eating and drinking normally and capillary ketones are < 0.6 mmol.l-1 1.
- Written sick-day rules should be provided to patients at pre-operative assessment and at discharge 1.
It is also important to note that the evidence base for the management of SGLT2 inhibitors in the perioperative period is limited, and further studies are needed to inform best practice 1. However, based on the available evidence, discontinuing SGLT2 inhibitors at least 3-4 days before elective surgery and not restarting until the patient is eating and drinking normally postoperatively is the recommended approach. Patients should be monitored for signs of ketoacidosis (nausea, vomiting, abdominal pain, fatigue, and rapid breathing) even if blood glucose levels are not significantly elevated. For emergency surgeries where the medication cannot be stopped in advance, close monitoring of ketone levels, acid-base status, and more aggressive hydration may be necessary. The medication can typically be resumed once the patient has recovered from surgery, is eating normally, and kidney function has been assessed as stable.
From the Research
Perioperative Use of SGLT2 Inhibitors
- The use of Sodium-Glucose Linked Transporter 2 (SGLT2) inhibitors in the perioperative period has been associated with an increased risk of euglycemic diabetic ketoacidosis (DKA) 2, 3, 4.
- Studies have shown that discontinuing SGLT2 inhibitors at least 24-48 hours before surgery may minimize this risk 2, 3, 5.
- However, a case report found that euglycemic DKA can occur even 48 hours after discontinuation of SGLT2 inhibitor therapy 2.
- A retrospective analysis found a strong association between decreased hold time and postoperative anion gap, suggesting that holding SGLT2 inhibitors before surgery may reduce the risk of anion gap acidosis 4.
- There is ongoing debate about the management of SGLT2 inhibitors in the perioperative period, with some evidence suggesting that withholding them can lead to more surgical complications and poorer glycaemic control 6.
Key Considerations
- Patients receiving SGLT2 inhibitors preoperatively are at risk of developing euglycemic DKA, and anesthesiologists should be aware of this potential complication 3.
- Monitoring of anion gap and serum ketones can help detect clinically significant euglycemic DKA, particularly in patients undergoing emergency surgery 4.
- A multidisciplinary approach is recommended for the management of patients on SGLT2 inhibitors in the perioperative period 5.