Do you need to stop Farxiga (dapagliflozin) before surgery?

Perioperative Management of Farxiga (Dapagliflozin)

Farxiga (dapagliflozin) should be withheld for at least 3 days prior to major surgery or procedures associated with prolonged fasting, and resumed when the patient is clinically stable and has resumed oral intake. 1

Rationale for Stopping Farxiga Before Surgery

Dapagliflozin, as an SGLT2 inhibitor, carries specific perioperative risks that necessitate temporary discontinuation:

1. Risk of Diabetic Ketoacidosis (DKA):

   • Surgery and fasting are precipitating factors for DKA in patients taking SGLT2 inhibitors
   • DKA can occur even with normal or only slightly elevated blood glucose levels ("euglycemic DKA")
   • This risk is significantly increased during perioperative periods due to stress response and reduced oral intake

2. Volume Depletion Concerns:

   • Dapagliflozin causes osmotic diuresis which may exacerbate perioperative volume depletion
   • This can potentially lead to hypotension, especially during anesthesia

Timing of Discontinuation

The FDA-approved drug label for dapagliflozin specifically recommends:

• Withhold Farxiga for at least 3 days prior to major surgery or procedures associated with prolonged fasting 1
• This timeframe allows for clearance of the medication and reduction of associated risks

Resumption After Surgery

Dapagliflozin should be resumed:

• When the patient is clinically stable
• After oral intake has been adequately resumed
• After confirming normal renal function post-surgery

Special Considerations

Renal Function

• Assess renal function prior to resuming dapagliflozin
• Major surgery may temporarily affect renal function
• Dapagliflozin is not recommended for glycemic control in patients with eGFR <45 mL/min/1.73m² 1

Risk Factors to Monitor

• Dehydration
• Reduced caloric intake during recovery
• Acute illness or surgical complications
• Inadequate insulin dosing (if applicable)

Monitoring for Complications

• Monitor for signs of DKA (nausea, vomiting, abdominal pain, malaise, shortness of breath)
• Consider ketone monitoring in high-risk patients
• Be vigilant for signs of volume depletion or hypotension

Comparison to Other Antidiabetic Medications

Unlike metformin, which is recommended to be stopped the night before surgery and not restarted before 48 hours for major surgery (after confirming adequate renal function) 2, dapagliflozin requires a longer pre-operative discontinuation period due to its unique mechanism of action and risk profile.

Common Pitfalls to Avoid

1. Inadequate discontinuation period: Not stopping dapagliflozin early enough before surgery
2. Premature resumption: Restarting too soon before adequate oral intake is established
3. Failure to monitor: Not watching for signs of DKA during the perioperative period
4. Overlooking renal function: Not assessing kidney function before resuming the medication

By following these guidelines, the risk of perioperative complications related to dapagliflozin therapy can be minimized while maintaining optimal long-term management of the patient's underlying condition.