Should an adult patient with type 2 diabetes on empagliflozin (Jardiance) stop the medication before a planned surgery, and how many days in advance?

Yes, Hold Jardiance Before Surgery

You should stop Jardiance (empagliflozin) the day before surgery, which provides a minimum 36-52 hour gap depending on timing, though 3-4 days is recommended for higher-risk patients. 1, 2

Timing of Discontinuation

The most recent 2025 multidisciplinary UK consensus guideline recommends omitting SGLT2 inhibitors the day before and the day of the procedure 1. This translates to:

• Minimum 48 hours if taking morning dose and having morning surgery
• 52+ hours if taking morning dose and having afternoon surgery
• Minimum 36 hours if taking evening dose

However, the 2025 American Diabetes Association guidelines and FDA recommendations are more conservative, advising discontinuation 3-4 days before surgery 2, 3.

Why This Matters: The Ketoacidosis Risk

The primary concern is euglycemic diabetic ketoacidosis (euDKA) - a life-threatening condition where you develop dangerous ketoacidosis even with normal blood sugar levels 1, 4. This is particularly insidious because:

• Normal glucose levels (often <250 mg/dL) can mask the severity
• Surgical stress, fasting, and reduced carbohydrate intake amplify ketone production
• The risk increases from 0.69 to 1.02 per 1000 patients when SGLT2 inhibitors are continued 1
• Emergency surgery carries 6.5x higher risk (1.1% vs 0.17%) compared to elective procedures 1, 5

Importantly, ketoacidosis has occurred even when patients held the drug for >72 hours, emphasizing this is a risk continuum rather than an absolute threshold 1.

Risk-Stratified Approach

For standard elective surgery (lower risk):

• Stop the day before surgery (36-52 hour gap) 1
• Ensure adequate hydration
• Avoid prolonged fasting
• Monitor glucose and ketones perioperatively

For higher-risk patients, use the 3-4 day rule if:

• Insulin-dependent diabetes
• History of ketoacidosis
• Major/prolonged surgery expected
• Significant comorbidities (renal/hepatic impairment)
• Expected prolonged postoperative fasting 2, 6

The Competing Risk: Cardiovascular and Renal Protection

This creates a clinical dilemma. While stopping Jardiance reduces ketoacidosis risk, emerging evidence shows:

• Preoperative SGLT2 inhibitor use associates with lower acute kidney injury and short-term mortality 7
• Stopping in heart failure patients may worsen heart failure 1
• Cardiovascular and volume-regulatory benefits may diminish rapidly after interruption 7

However, these observational findings do not justify routine continuation - they simply highlight the need for individualized timing based on the primary indication (diabetes vs. heart failure vs. chronic kidney disease) 7.

Critical Perioperative Safeguards

Before surgery:

• Confirm patient actually stopped the medication
• Ensure adequate hydration status
• Check baseline ketones if available

During/after surgery:

• Maintain glucose 100-180 mg/dL 2
• Use glucose-containing IV fluids if prolonged fasting expected 1
• Check ketones if any concerning symptoms develop, even with normal glucose 1, 3

Warning signs of ketoacidosis:

• Nausea, vomiting, abdominal pain
• Unusual fatigue or trouble breathing
• These require immediate ketone/acid-base assessment 3, 4

When to Restart

For outpatient surgery:

• Restart once eating and drinking normally (usually 24-48 hours post-op) 1

For inpatient surgery:

• Restart once eating/drinking normally AND capillary ketones <0.6 mmol/L 1

Common Pitfalls to Avoid

1. Don't assume normal glucose means no ketoacidosis - this is the defining feature of euDKA
2. Don't forget to counsel patients preoperatively - in one series, only 1 of 3 non-emergent euDKA cases received proper counseling 5
3. Don't restart too early - ensure adequate oral intake and normal ketone levels first
4. Don't use the same timing for emergency surgery - these patients need intensive monitoring as the drug cannot be prophylactically stopped 5

The balance tips toward the conservative 3-4 day discontinuation for most elective surgeries given the severity of euDKA, though the 1-2 day approach may be reasonable for very low-risk procedures in non-insulin-dependent patients with robust monitoring capabilities 1, 2.