Perioperative Management of Jardiance (Empagliflozin)
Jardiance (empagliflozin) should be discontinued 3-4 days before surgery to reduce the risk of perioperative euglycemic diabetic ketoacidosis. 1, 2
Rationale for Discontinuation
SGLT2 inhibitors like Jardiance carry a unique risk profile in the perioperative setting:
- They increase the risk of euglycemic diabetic ketoacidosis (eDKA), a serious complication that can be difficult to detect due to relatively normal blood glucose levels 3
- The American Diabetes Association, American Heart Association, and American College of Cardiology all recommend discontinuing SGLT2 inhibitors 3-4 days before elective surgery 1, 2
- The incidence of eDKA is significantly higher in emergency surgeries (1.1%) compared to elective procedures where the medication is appropriately held (0.17%) 3
Specific Recommendations
Timing of Discontinuation
- For elective surgery: Stop Jardiance 3 days before the scheduled procedure 1, 2
- For emergency surgery: Be vigilant for signs of eDKA even with normal glucose levels 3
Perioperative Monitoring
- Monitor blood glucose every 2-4 hours while the patient is NPO 1
- Target perioperative blood glucose range: 100-180 mg/dL (5.6-10.0 mmol/L) 1, 2
- Be alert for metabolic acidosis even with normal glucose levels 4
Resumption After Surgery
- Do not restart Jardiance until:
- Patient is eating normally
- Renal function has been assessed and is stable
- No signs of acute illness or metabolic derangement are present 2
Special Considerations
Diabetes Management During SGLT2i Discontinuation
- For patients with type 2 diabetes, alternative glucose-lowering strategies may be needed during the perioperative period when Jardiance is held
- Short or rapid-acting insulin may be used as needed for glycemic control 1
- Avoid overly strict glycemic targets (<100 mg/dL) as they increase hypoglycemia risk without improving outcomes 1, 2
Risk Factors for Complications
- Emergency surgery (unable to discontinue medication in advance) 3
- Acute illness, especially infections like COVID-19 4
- Reduced carbohydrate intake or fasting 4
- Renal impairment 5
Common Pitfalls to Avoid
- Failing to discontinue Jardiance early enough before elective procedures
- Missing signs of euglycemic DKA due to normal glucose levels
- Restarting Jardiance too soon after surgery before ensuring metabolic stability
- Inadequate monitoring of acid-base status in patients who were on Jardiance and undergo emergency surgery
By following these guidelines, the risk of perioperative complications related to Jardiance can be significantly reduced while maintaining adequate glycemic control.