Why is it necessary to withhold Jardiance (Empagliflozin) prior to surgery?

Perioperative Management of Jardiance (Empagliflozin)

Jardiance (empagliflozin) should be discontinued at least 3 days prior to major surgery or procedures associated with prolonged fasting to prevent the risk of diabetic ketoacidosis (DKA). 1

Rationale for Withholding Jardiance Before Surgery

Risk of Diabetic Ketoacidosis

• SGLT2 inhibitors like Jardiance increase the risk of ketoacidosis, a serious life-threatening condition requiring urgent hospitalization 2
• This risk is particularly concerning in the perioperative setting due to:
  • Fasting state (reduced caloric intake)
  • Surgical stress
  • Volume depletion
  • Potential renal impairment

Evidence of Perioperative Risk

• The risk of perioperative DKA in patients taking SGLT2 inhibitors is 48% higher than in those not taking these medications (1.02 vs. 0.69 per 1000 patients) 3
• The incidence of perioperative ketoacidosis is significantly higher in emergency surgery (1.1%) compared to elective surgery (0.17%) 4
• DKA can occur even with normal blood glucose levels (euglycemic DKA), making it harder to detect 3

Recommended Perioperative Protocol

Pre-operative Management

• For elective surgery:
  • Withhold Jardiance at least 3 days before major surgery 1
  • For minor or ambulatory surgery, withhold the day before and the day of surgery 3
• For emergency surgery:
  • Be aware of increased risk (1.1% incidence of euglycemic DKA) 4
  • Monitor ketones closely regardless of blood glucose levels

Intraoperative Considerations

• Monitor for signs of volume depletion and hypotension 2
• Consider glucose-containing IV fluids during prolonged procedures to mitigate ketone generation 3
• Be vigilant for signs of metabolic acidosis regardless of blood glucose levels

Post-operative Management

• Do not restart Jardiance for at least 48 hours after major surgery 3
• Before restarting, ensure:
  • Patient is eating and drinking normally
  • Renal function is adequate (eGFR ≥45 mL/min/1.73m²) 1
  • Capillary ketones are <0.6 mmol/L 3
  • No signs of acute kidney injury

Warning Signs to Monitor

• Signs of DKA that may occur regardless of blood glucose levels:

  • Nausea and vomiting
  • Abdominal pain
  • Malaise
  • Shortness of breath
  • Metabolic acidosis

• Signs of acute kidney injury:

  • Decreased urine output
  • Elevated creatinine
  • Fluid retention

Clinical Pitfalls to Avoid

1. Failure to recognize euglycemic DKA: DKA can occur with blood glucose levels below 250 mg/dL in patients taking SGLT2 inhibitors 2

2. Inadequate pre-operative discontinuation: Reports show ketoacidosis can occur even when SGLT2 inhibitors are withheld for >72 hours in some cases 3

3. Premature restart: Restarting too soon after surgery before ensuring adequate oral intake and renal function can precipitate complications 3

4. Overlooking volume status: Jardiance causes intravascular volume contraction that can worsen with surgical stress 2

5. Neglecting renal function: Surgery may temporarily affect renal function, and Jardiance should not be used when eGFR is <45 mL/min/1.73m² 1

By following these guidelines, the risk of perioperative complications related to Jardiance therapy can be minimized while maintaining optimal glycemic control during the surgical period.