Can Sodium-Glucose Linked Transporter 2 (SGLT2) inhibitors and Glucagon-Like Peptide-1 (GLP-1) analogues be initiated in patients post-orthopedic surgeries?

Management of SGLT2 Inhibitors and GLP-1 Analogues Post-Orthopedic Surgery

SGLT2 inhibitors should not be initiated immediately post-orthopedic surgery due to the risk of euglycemic diabetic ketoacidosis, while GLP-1 receptor agonists can be safely started once patients are eating and drinking normally. 1, 2

SGLT2 Inhibitors Post-Orthopedic Surgery

Risks of Early Initiation

• SGLT2 inhibitors cause euglycemic DKA through altered insulin-glucagon ratio, leading to decreased insulin secretion and increased glucagon, promoting ketogenesis despite normal glucose levels 2
• The risk of perioperative DKA is higher in patients taking SGLT2 inhibitors compared to those not taking them (1.02 vs. 0.69 per 1000 patients) 3
• Emergency surgery carries a higher risk of DKA than elective surgery (1.1% vs. 0.17%) 2, 3
• Postoperative ketoacidosis can occur even when patients have withheld SGLT2 inhibitors for >72 hours 1

Recommendations for Initiation

• Do not start SGLT2 inhibitors immediately post-orthopedic surgery 1, 2
• SGLT2 inhibitors should only be initiated once the patient is:
  • Eating and drinking normally (usually 24-48 hours after surgery) 1, 2
  • Clinically stable with no signs of dehydration 2
  • For inpatients, capillary ketones should be <0.6 mmol/L before initiation 1

Risk Mitigation When Starting SGLT2 Inhibitors

• Ensure adequate hydration and avoid prolonged fasting periods 1, 2
• Monitor glucose and ketone levels regularly 2
• Provide written sick-day rules to patients at discharge 1
• Educate patients about symptoms of euglycemic DKA (nausea, vomiting, abdominal pain, generalized weakness) 3

GLP-1 Receptor Agonists Post-Orthopedic Surgery

Safety Considerations

• GLP-1 receptor agonists can be continued during the perioperative period 1, 4
• The main concern with GLP-1 agonists is delayed gastric emptying, which could potentially increase aspiration risk 5
• However, the effect on gastric emptying diminishes with long-term use 5

Recommendations for Initiation

• GLP-1 receptor agonists can be initiated post-orthopedic surgery once the patient is eating and drinking normally 1, 5
• Start with the lowest dose and titrate gradually to minimize gastrointestinal side effects 6
• Consider the specific formulation's dosing schedule (daily vs. weekly) when initiating therapy 6

Special Considerations

Heart Failure Patients

• For patients with heart failure, cessation of SGLT2 inhibitors may be associated with worsening heart failure 1, 2
• In these patients, carefully weigh the benefits of early initiation against the risks of euglycemic DKA 2

Non-Diabetic Patients

• Non-diabetic patients taking SGLT2 inhibitors for heart failure or chronic kidney disease are still at risk of euglycemic DKA 2, 3
• These patients may not have sufficient insulin to prevent significant ketosis 2

Very Low Energy/Liver Reduction Diet

• For patients on a very low energy/liver reduction diet post-surgery, do not initiate SGLT2 inhibitors as this diet already induces ketosis 1
• The combination could lead to significant ketoacidosis 1

Algorithm for Initiating These Medications Post-Orthopedic Surgery

1. For GLP-1 Receptor Agonists:

   • Wait until patient is eating and drinking normally 1, 5
   • Start at lowest dose and titrate gradually 6
   • Monitor for gastrointestinal side effects 5

2. For SGLT2 Inhibitors:

   • Wait at least 24-48 hours post-surgery 1, 2
   • Ensure patient is eating and drinking normally 1
   • Check capillary ketones (<0.6 mmol/L) before initiation if inpatient 1
   • Provide written sick-day rules 1
   • Monitor for signs of euglycemic DKA 2, 3