When to Hold Dapagliflozin (Farxiga) Before Procedures or Stress Testing
Dapagliflozin should be withheld for at least 3 days prior to major surgery or procedures associated with prolonged fasting that may affect kidney function or increase hypotension risk. 1
General Recommendations for Holding Dapagliflozin
Procedures with Risk of Kidney Function Impact
- Hold dapagliflozin at least 3 days before major surgical procedures or interventions associated with prolonged fasting periods, as explicitly stated in the FDA label 1
- For procedures with contrast administration or that may affect renal function, withholding dapagliflozin is recommended to reduce the risk of acute kidney injury 2
- Check renal function before angiography if patients have taken dapagliflozin, and withhold the medication if renal function deteriorates 2
Procedures Based on Bleeding Risk
While specific guidance for SGLT2 inhibitors like dapagliflozin is limited, procedural risk stratification can be applied:
- For high-bleeding risk procedures (cardiac surgery, intracranial surgery, major operations >45 min, neuraxial anesthesia): Hold dapagliflozin for at least 3 days 2, 1
- For low-to-moderate bleeding risk procedures (arthroscopy, colonoscopy, laparoscopic procedures): Hold dapagliflozin for at least 24 hours 2
- For minimal bleeding risk procedures (minor dermatologic procedures, cataract surgery, dental procedures): May not require holding dapagliflozin 2
Stress Testing Considerations
- For stress tests involving contrast agents: Hold dapagliflozin for at least 24 hours before the procedure 2
- For exercise stress testing without contrast: No specific need to hold dapagliflozin unless combined with significant fasting 1
Special Considerations
Renal Function Impact
- Patients with impaired renal function (eGFR <45 mL/min/1.73m²) may require longer periods of withholding dapagliflozin before procedures due to slower drug clearance 1, 3
- Monitor renal function before resuming dapagliflozin after procedures, especially if the patient experienced volume depletion or hypotension 1
Cardiovascular Procedures
- For patients undergoing cardiac procedures, dapagliflozin should be withheld for at least 3 days to minimize risk of volume depletion and hypotension during anesthesia 2, 1
- For coronary angiography, check renal function before the procedure and withhold dapagliflozin if renal function deteriorates 2
Volume Status Considerations
- Assess volume status before procedures and correct volume depletion before resuming dapagliflozin 1
- Patients on diuretics in addition to dapagliflozin may require special attention to volume status before procedures 2
Resuming Dapagliflozin After Procedures
- Resume dapagliflozin only after adequate oral intake has been established and patient is hemodynamically stable 1
- Assess renal function before restarting dapagliflozin, particularly after major procedures 1
- For patients who have experienced acute kidney injury during the perioperative period, delay resumption until renal function has stabilized 2
Common Pitfalls to Avoid
- Failing to withhold dapagliflozin before major procedures can increase risk of volume depletion and hypotension during anesthesia 2, 1
- Resuming dapagliflozin too early after procedures before adequate oral intake is established may increase risk of dehydration and acute kidney injury 1
- Not considering the additive effects of other medications that affect volume status (diuretics, ACE inhibitors) when planning perioperative management 2