Is empagliflozin (Jardiance) safe to use during the perioperative period?

Perioperative Management of Empagliflozin

Empagliflozin should be discontinued at least 3 days before any scheduled surgery to reduce the risk of perioperative diabetic and euglycemic ketoacidosis. 1

Rationale for Discontinuation

Empagliflozin, a sodium-glucose cotransporter-2 (SGLT-2) inhibitor, has demonstrated significant cardiovascular and renal benefits in patients with type 2 diabetes. However, its use in the perioperative period carries specific risks:

• Increased risk of ketoacidosis: SGLT-2 inhibitors can cause both diabetic and euglycemic ketoacidosis in the perioperative setting 1
• Potential for volume depletion: The diuretic effect may contribute to hemodynamic instability during surgery
• Risk of acute kidney injury: While offering long-term renal benefits, acute surgical stress combined with SGLT-2 inhibition may temporarily compromise renal function

Specific Recommendations

1. Timing of discontinuation:

   • Stop empagliflozin ≥3 days before scheduled surgery 1
   • This recommendation applies to all types of surgeries, including cardiac and non-cardiac procedures

2. Resumption after surgery:

   • Resume empagliflozin only when the patient is:
     • Clinically stable
     • Taking adequate oral intake
     • Showing no signs of acute kidney injury
     • Typically 2-3 days after surgery for major procedures

3. Special considerations:

   • For patients with heart failure: Despite the benefits of empagliflozin in heart failure management 2, the drug should still be discontinued preoperatively due to ketoacidosis risk
   • For emergency surgeries: If empagliflozin was not discontinued, monitor closely for signs of ketoacidosis, including metabolic acidosis with normal or only slightly elevated blood glucose

Monitoring Recommendations

During the perioperative period after recent empagliflozin use:

• Monitor for signs of ketoacidosis (nausea, vomiting, abdominal pain, fatigue, and fruity-scented breath)
• Check acid-base status if clinically indicated
• Ensure adequate hydration
• Monitor renal function

Alternative Management During Perioperative Period

While empagliflozin is held:

• For glycemic control: Use insulin-based regimens as needed
• For heart failure patients: Continue other guideline-directed medical therapy excluding SGLT-2 inhibitors

Common Pitfalls

• Failure to discontinue: Not stopping empagliflozin before surgery increases risk of perioperative ketoacidosis
• Premature resumption: Restarting too early before adequate oral intake and clinical stability is established
• Overlooking benefits: While perioperative risks exist, remember the long-term cardiovascular and renal benefits of empagliflozin 3, 4 when planning postoperative medication regimens

The evidence clearly supports temporarily discontinuing empagliflozin in the perioperative period, with careful planning for resumption once the patient has recovered from surgery.