Is it okay to proceed with cataract surgery in a patient taking Farxiga (dapagliflozin) for heart failure without holding the medication?

Management of Dapagliflozin (Farxiga) During Cataract Surgery

It is safe to proceed with cataract surgery in a patient taking Farxiga (dapagliflozin) for heart failure without holding the medication on the day of surgery. The benefits of maintaining heart failure therapy outweigh any theoretical risks in this specific surgical context.

Perioperative Management of Heart Failure Medications

• According to European Society of Cardiology (ESC) guidelines, it is generally recommended that all heart failure medications be continued throughout the perioperative period with appropriate hemodynamic monitoring 1
• While some medications like ACEIs/ARBs may be omitted on the morning of surgery due to hypotension risk, there is no specific recommendation to discontinue SGLT2 inhibitors like dapagliflozin before minor surgeries such as cataract procedures 1
• Cataract surgery is considered a low-risk procedure that typically uses topical or intracameral anesthesia, which carries minimal systemic risks even for patients on cardiovascular medications 2

Specific Considerations for SGLT2 Inhibitors

• The 2024 AHA/ACC guidelines specifically recommend withholding SGLT2 inhibitors like dapagliflozin for 3-4 days before surgery "when feasible" to reduce the risk of perioperative metabolic acidosis 1
• However, this recommendation is primarily directed at intermediate to high-risk surgeries where fluid shifts, hemodynamic changes, and fasting periods are significant 1
• Cataract surgery:
  • Is typically brief (15-30 minutes)
  • Involves minimal fluid shifts
  • Has limited impact on systemic hemodynamics
  • Usually does not require prolonged fasting 2

Risk-Benefit Analysis

• Benefits of continuing dapagliflozin:

  • Maintains optimal heart failure management 3, 4
  • Prevents potential heart failure exacerbation from medication interruption 5
  • Avoids complications from suboptimal heart failure control during perioperative period 1

• Risks of continuing dapagliflozin during cataract surgery:

  • Theoretical risk of metabolic acidosis is minimal given the brief nature of the procedure and limited fasting time 1
  • No specific evidence suggests increased surgical complications in cataract procedures 2

Practical Recommendations

• Proceed with cataract surgery without holding dapagliflozin 1, 2
• Ensure proper hydration before and after the procedure to minimize any risk of dehydration 5
• Monitor for any signs of hypotension during the procedure, although this is unlikely with topical anesthesia 2
• Resume normal medication schedule and fluid intake immediately after surgery 1

Important Caveats

• This recommendation applies specifically to cataract surgery, which is a minor procedure with minimal systemic effects 2
• For major surgeries requiring prolonged fasting or with significant fluid shifts, the standard recommendation to hold SGLT2 inhibitors for 3-4 days would still apply 1
• Patients with additional comorbidities like severe renal dysfunction may require individualized assessment 6