Why is Jardiance (Empagliflozin) stopped before surgical cases?

Perioperative Management of Jardiance (Empagliflozin)

Jardiance (empagliflozin) should be withheld for 3 days before elective surgery to reduce the risk of perioperative euglycemic diabetic ketoacidosis. 1

Rationale for Discontinuation

SGLT2 inhibitors like Jardiance work by increasing urinary glucose excretion, which creates several perioperative risks:

• Euglycemic Diabetic Ketoacidosis (eDKA): The primary concern with continuing Jardiance perioperatively is the risk of developing eDKA, a serious life-threatening condition requiring urgent hospitalization 2. This condition can occur even with relatively normal blood glucose levels (below 250 mg/dL).

• Volume Depletion: Jardiance causes intravascular volume contraction that can lead to hypotension during anesthesia 2.

• Acute Kidney Injury: The combination of surgery-related stress, fasting, and SGLT2 inhibition increases the risk of acute kidney injury 2.

Timing of Discontinuation

The 2024 AHA/ACC guideline specifically recommends:

• Canagliflozin, dapagliflozin, and empagliflozin should be stopped ≥3 days before scheduled surgery
• Ertugliflozin should be stopped ≥4 days before scheduled surgery 1

This timing allows sufficient clearance of the drug to minimize the risk of metabolic complications. The 2025 consensus statement from the Association of Anaesthetists and other organizations reinforces this recommendation, stating that SGLT2 inhibitors should be omitted the day before and the day of a procedure 1.

Evidence Supporting Discontinuation

Research shows that:

• The incidence of perioperative eDKA is higher in patients taking SGLT2 inhibitors compared to those who are not (1.02 vs. 0.69 per 1000 patients) 1
• The risk of eDKA is significantly higher in emergency surgeries (1.1%) compared to elective procedures (0.17%) 3
• Omitting SGLT2 inhibitors >2 days pre-operatively has been associated with prevention of eDKA 1

Special Considerations

Patients with Heart Failure

While discontinuation of SGLT2 inhibitors in patients receiving them for heart failure may be associated with worsening heart failure 1, the risk of perioperative eDKA outweighs this concern for the short perioperative period.

Emergency Surgery

For emergency surgeries where adequate discontinuation time is not possible:

• Implement more vigilant monitoring for ketoacidosis
• Consider checking serum ketones preoperatively
• Be alert for signs of metabolic acidosis even with normal blood glucose levels 3

Resumption Guidelines

• For outpatients discharged on the day of surgery: restart once eating and drinking normally (usually 24-48 hours after surgery)
• For inpatients: restart once eating and drinking normally and capillary ketones are <0.6 mmol/L 1
• Always ensure adequate renal function before restarting 2

Common Pitfalls to Avoid

1. Failure to recognize eDKA: eDKA can occur with normal or only slightly elevated blood glucose levels. Monitor for metabolic acidosis regardless of glucose levels.

2. Inadequate patient education: Ensure patients understand the importance of stopping Jardiance before surgery and when to restart it.

3. Prolonged fasting: Minimize fasting periods as much as possible to reduce the risk of ketone formation.

4. Overlooking hydration status: Maintain adequate hydration perioperatively to reduce the risk of acute kidney injury.

5. Restarting too early: Do not restart Jardiance until the patient is eating and drinking normally and has stable renal function.

By following these guidelines, the risk of perioperative complications related to Jardiance can be significantly reduced while maintaining optimal long-term diabetes management.