Dapagliflozin Management in Surgical Procedures
Dapagliflozin (Forxiga) should be discontinued at least 3 days before any scheduled surgery to reduce the risk of perioperative metabolic acidosis. 1
Preoperative Management
Timing of Discontinuation
- For all elective surgical procedures: Stop dapagliflozin at least 3 days before surgery 1, 2
- This recommendation applies to:
- Patients taking dapagliflozin for type 2 diabetes
- Patients taking dapagliflozin for heart failure
- Patients taking dapagliflozin for chronic kidney disease
Risk Assessment
The primary concern with perioperative dapagliflozin use is the risk of diabetic ketoacidosis (DKA), including euglycemic DKA, which can be difficult to diagnose due to potentially normal blood glucose levels. Several factors increase this risk:
- Fasting state before surgery
- Surgical stress response
- Reduced oral intake postoperatively
- Volume depletion
- Acute illness related to surgery
Procedure-Specific Considerations
High-Bleeding Risk Procedures
For high-bleeding risk procedures (cardiac surgery, neurosurgery, major abdominal surgery):
- Discontinue dapagliflozin 3 days before surgery 1
- Resume dapagliflozin 2-3 days after surgery when the patient is clinically stable and has resumed normal oral intake 1, 2
Low-to-Moderate Bleeding Risk Procedures
For low-to-moderate bleeding risk procedures (endoscopy, arthroscopy, minor surgeries):
- Still discontinue dapagliflozin 3 days before surgery 1
- May resume dapagliflozin as early as 24 hours after surgery if patient is clinically stable with normal oral intake 1
Postoperative Resumption
When to Resume Dapagliflozin
- Resume only when the patient is clinically stable 2
- Ensure adequate oral intake has been established 2
- Verify absence of postoperative complications that might increase ketoacidosis risk
Special Considerations for Resumption
- For patients at high risk of heart failure exacerbation, consider resuming dapagliflozin earlier (24-48 hours post-surgery) if clinically stable 1
- For patients with impaired renal function (eGFR <45 mL/min/1.73m²), exercise additional caution when resuming therapy 3
Monitoring Recommendations
Preoperative Monitoring
- Assess renal function before surgery
- Evaluate volume status and correct any volume depletion before surgery 2
Postoperative Monitoring
- Monitor for signs of ketoacidosis regardless of blood glucose levels (nausea, vomiting, abdominal pain, malaise, shortness of breath) 2
- Check serum ketones if there is clinical suspicion of ketoacidosis
- Monitor renal function, especially in patients undergoing procedures with high risk of acute kidney injury
Special Populations
Cardiac Surgery Patients
While some preliminary research suggests potential benefits of dapagliflozin in cardiac surgery patients 4, current guidelines still recommend discontinuation due to the risk of ketoacidosis 1.
Heart Failure Patients
For patients with heart failure taking dapagliflozin:
- Still discontinue dapagliflozin 3 days before surgery 1
- Resume guideline-directed medical therapy (excluding SGLT2i) in the perioperative period 1
- Resume dapagliflozin when clinically stable postoperatively
Common Pitfalls to Avoid
- Failure to discontinue dapagliflozin preoperatively: This increases risk of euglycemic DKA which can be difficult to diagnose
- Resuming too early postoperatively: Wait until the patient has stable oral intake
- Overlooking ketoacidosis due to normal glucose levels: SGLT2 inhibitors can cause euglycemic DKA
- Neglecting volume status: Ensure adequate hydration before resuming dapagliflozin
By following these guidelines for perioperative management of dapagliflozin, clinicians can minimize the risk of complications while maintaining the long-term benefits of this medication for patients with diabetes, heart failure, or chronic kidney disease.