From the Guidelines
SGLT2 inhibitors, such as canagliflozin, dapagliflozin, and empagliflozin, should be discontinued at least 3-4 days before colonoscopy to minimize the risk of euglycemic diabetic ketoacidosis (euDKA) and ensure optimal perioperative management. This recommendation is based on the most recent and highest quality evidence available, including the study by El-Boghdadly et al. published in 2025 1. The mechanism of action of SGLT2 inhibitors, which increases urinary glucose excretion, can lead to volume depletion and create a perfect scenario for ketosis and acidosis when combined with reduced oral intake during bowel preparation.
Key Considerations for Perioperative Management
- Discontinue SGLT2 inhibitors 3-4 days before colonoscopy to reduce the risk of euDKA
- Hold SGLT2 inhibitors on the day of bowel preparation and the day of the procedure
- Do not resume SGLT2 inhibitors until normal eating and drinking patterns have been established for 24-48 hours after the procedure
- Monitor blood glucose levels more frequently during this period and consider temporary insulin or alternative diabetes medications as directed by the healthcare provider
- Educate patients about the symptoms of euDKA, such as nausea, vomiting, abdominal pain, fatigue, and rapid breathing, and instruct them to seek immediate medical attention if these develop
Rationale for Recommendation
The recommendation to discontinue SGLT2 inhibitors before colonoscopy is supported by the evidence, which suggests that cessation of these medications can reduce the risk of high anion gap acidosis and perioperative ketoacidosis 1. Additionally, the study by El-Boghdadly et al. highlights the importance of balancing the risks of stopping SGLT2 inhibitors against the risks of deferring or cancelling a procedure due to preoperative hyperglycemia and postoperative complications.
Additional Considerations
- Ensure patients remain well-hydrated and avoid long starvation periods to mitigate the risk of complications
- Consider glucose-containing intravenous fluids in settings of unplanned or unavoidable prolonged fasting to mitigate ketone generation
- Provide individualized care and consider the specific needs and circumstances of each patient when making decisions about perioperative management of SGLT2 inhibitors.
From the Research
Perioperative Management of SGLT2 Inhibitors for Colonoscopy
- The current evidence suggests that SGLT2 inhibitors should be discontinued at least 24 hours before surgery to minimize the risk of euglycemic diabetic ketoacidosis (DKA) 2, 3.
- However, some studies suggest that this may not be sufficient, and the risk of euglycemic DKA may persist even after 48 hours of discontinuation 2.
- A dose-dependent relationship between SGLT2 inhibitor hold time and risk for postoperative anion gap acidosis has been observed, with decreased hold time associated with increased risk 4.
- The management of SGLT2 inhibitors in the perioperative period is still a topic of debate, with some arguing for withholding and others for continuing the medication 5.
- A recent study found that preoperative use of SGLT2 inhibitors was not associated with an increased risk of postoperative diabetic ketoacidosis in patients undergoing emergency surgery, which may justify liberalizing current guidance on preoperative SGLT2 inhibitor withholding periods 6.
Recommendations for Colonoscopy
- Based on the available evidence, it is recommended that patients discontinue SGLT2 inhibitors at least 24 hours before colonoscopy to minimize the risk of euglycemic DKA 2, 3.
- However, the decision to discontinue SGLT2 inhibitors should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history.
- Patients undergoing colonoscopy should be closely monitored for signs of euglycemic DKA, including elevated anion gap metabolic acidosis and blood ketone levels 2, 3.
- Further studies are needed to determine the optimal perioperative management of SGLT2 inhibitors for colonoscopy.