What are the recommendations for managing Jardiance (Empagliflozin) in patients undergoing surgery?

Management of Jardiance (Empagliflozin) in Patients Undergoing Surgery

SGLT2 inhibitors like Jardiance (empagliflozin) should be discontinued 3-4 days before surgery to reduce the risk of euglycemic diabetic ketoacidosis. 1

Preoperative Management

Timing of Discontinuation

• For elective surgeries:
  • Discontinue Jardiance 3-4 days before surgery 2, 1
  • This timeframe allows for complete clearance of the medication from the system
  • For cataract or other minor procedures, a minimum 48-hour gap is required before a morning procedure and 36-hour gap for evening procedures 1

Risk Assessment

• The primary concern with perioperative SGLT2 inhibitor use is euglycemic diabetic ketoacidosis (euDKA) 1
• euDKA can occur even with normal blood glucose levels, making it particularly dangerous 1
• Risk factors that require special attention:
  • Renal insufficiency
  • Dehydration
  • Prolonged fasting
  • Concomitant use of medications that affect renal function (ACE inhibitors, diuretics, NSAIDs) 2

Additional Medication Management

• Metformin: Hold on the day of surgery 2
• Other oral antidiabetics: Hold on the morning of surgery 2
• NPH insulin: Administer at half the usual dose on surgery day 2
• Long-acting insulin: Administer at 75-80% of usual dose 2
• Consider reducing basal insulin by 25% the evening before surgery for better perioperative glucose control 2

Intraoperative Management

Glycemic Targets

• Maintain blood glucose between 100-180 mg/dL (5.6-10.0 mmol/L) during surgery 2, 1
• Monitor blood glucose every 2-4 hours while the patient is fasting 2
• Use short- or rapid-acting insulin as needed to maintain target glucose levels 2

Fluid Management

• Ensure adequate hydration to reduce the risk of euDKA 1
• Consider glucose-containing IV fluids for prolonged fasting periods 1
• Most patients require crystalloids at a rate of 1-4 ml/kg/h to maintain homeostasis 2

Postoperative Management

Resuming Jardiance

• Only restart Jardiance when:
  1. Patient is eating and drinking normally (usually 24-48 hours after surgery)
  2. Capillary ketones are <0.6 mmol/L
  3. No signs of metabolic derangement are present
  4. Renal function has been assessed and is stable 1

Monitoring

• Monitor for signs of euDKA even with normal glucose levels:
  • Nausea
  • Vomiting
  • Tachypnea
  • Anion gap metabolic acidosis 1
• Continue blood glucose monitoring every 2-4 hours until oral intake is established 2

Special Considerations

Emergency Surgery

• If a patient on Jardiance requires emergency surgery without adequate time for discontinuation:
  • Proceed with surgery but implement more intensive monitoring
  • Be vigilant for signs of euDKA even with normal glucose levels
  • Consider prophylactic IV fluids to maintain hydration 1

Heart Failure Patients

• For patients taking Jardiance for heart failure:
  • Balance the risk of ketoacidosis against the risk of worsening heart failure
  • More careful monitoring may be warranted if the decision is made to continue the medication 1

Ambulatory Surgery

• For short procedures where the patient doesn't miss a meal, treatment can be continued and the patient can have breakfast as usual 2
• If surgery is short and the patient can eat before 10 am, breakfast can be served and morning medication taken at that time 2

Common Pitfalls to Avoid

1. Failing to discontinue Jardiance early enough - The 3-4 day window is critical for reducing euDKA risk
2. Overlooking euDKA because glucose levels are normal - Remember that ketoacidosis can occur even with normal glucose levels
3. Restarting Jardiance too early - Wait until the patient is eating normally and metabolically stable
4. Inadequate hydration - Ensure proper fluid management to prevent dehydration
5. Missing signs of euDKA - Be vigilant for symptoms like nausea, vomiting, and tachypnea even when glucose levels are normal

By following these guidelines, the perioperative risk associated with Jardiance can be significantly reduced while maintaining adequate glycemic control throughout the surgical period.