Should Jardiance (Empagliflozin) be withheld before surgery?

Jardiance (Empagliflozin) Management Before Surgery

Jardiance (empagliflozin) should be discontinued at least 3 days before scheduled surgery to reduce the risk of perioperative metabolic acidosis. 1

Rationale for Discontinuation

• SGLT2 inhibitors like empagliflozin should be withheld for 3 days before elective surgery to prevent postoperative ketoacidosis, which can be life-threatening 1
• This recommendation has a Class 1 level of evidence (strong recommendation) according to the 2024 AHA/ACC guidelines for perioperative cardiovascular management 1
• Empagliflozin specifically should be stopped ≥3 days before scheduled surgery (ertugliflozin requires ≥4 days) 1
• The risk of euglycemic diabetic ketoacidosis is present even in non-diabetic patients taking SGLT2 inhibitors for heart failure 2

Mechanism of Risk

• SGLT2 inhibitors can cause euglycemic diabetic ketoacidosis in the perioperative period, which may present atypically with blood glucose levels below 250 mg/dL 3
• Perioperative factors that increase ketoacidosis risk include:
  • Fasting state 3
  • Surgical stress 3, 4
  • Volume depletion 3
  • Reduced caloric intake 3

Warning Signs of SGLT2i-Associated Ketoacidosis

• Symptoms may include: 3
  • Nausea, vomiting
  • Abdominal pain
  • Fatigue/malaise
  • Shortness of breath
  • Metabolic acidosis (even with normal or only slightly elevated blood glucose)

Special Considerations

• For emergency surgery when Jardiance has not been discontinued appropriately:

  • Monitor closely for signs of metabolic acidosis 4
  • Consider checking for ketones in urine or blood, even if blood glucose is <250 mg/dL 3
  • Maintain adequate hydration 3

• For patients taking Jardiance for heart failure:

  • The same discontinuation recommendation applies, even though the drug is being used for a cardiovascular indication rather than diabetes 1, 2
  • A case report documented postoperative ketoacidosis in a non-diabetic patient taking dapagliflozin (another SGLT2 inhibitor) for heart failure 2

Resuming Jardiance After Surgery

• Restart only after:
  • Patient is clinically stable 3
  • Oral intake has resumed 3
  • Renal function has been assessed and is adequate 3
  • No signs of metabolic acidosis are present 3

Contrast with Other Diabetes Medications

• Unlike SGLT2 inhibitors, metformin may be continued during the perioperative period in patients with normal renal function 1
• For patients on insulin, basal insulin should never be stopped completely, especially in Type 1 diabetes, due to risk of ketoacidosis 1

Summary

The evidence strongly supports withholding Jardiance (empagliflozin) for at least 3 days before scheduled surgery to prevent potentially life-threatening metabolic acidosis. This recommendation applies regardless of whether the medication is being used for diabetes or heart failure.