Should Dapagliflozin (Forxiga) be withheld prior to coronary angiography?

Should Dapagliflozin Be Withheld Prior to Coronary Angiography?

No, dapagliflozin does not need to be withheld prior to diagnostic coronary angiography, but it should be discontinued 3 days before scheduled coronary artery bypass graft (CABG) surgery if planned. 1

Key Distinction: Diagnostic vs. Surgical Procedures

For Diagnostic Coronary Angiography (PCI)

• Continue dapagliflozin through diagnostic coronary angiography and percutaneous coronary intervention (PCI) procedures 1
• The 2025 ACC/AHA guidelines specifically state that SGLT2 inhibitors should be stopped 3 days prior to scheduled surgery, including CABG, not diagnostic procedures 1
• Recent evidence demonstrates that dapagliflozin may actually provide renoprotective effects during contrast exposure in patients with type 2 diabetes and chronic kidney disease undergoing elective coronary procedures 2

For Scheduled CABG Surgery

• Discontinue dapagliflozin 3 days before planned CABG surgery 1
• This recommendation applies to canagliflozin, dapagliflozin, and empagliflozin (ertugliflozin requires 4 days) 1
• The rationale is to prevent perioperative diabetic ketoacidosis and euglycemic ketoacidosis, which carry higher risk in the surgical setting 1

Evidence Supporting Continuation During Angiography

Renal Protection During Contrast Exposure

• A 2023 propensity-matched study of 512 patients with type 2 diabetes and CKD undergoing elective coronary procedures found that dapagliflozin users had significantly lower post-contrast acute kidney injury (PC-AKI) rates (10.9% vs 22.3%) compared to non-users 2
• Dapagliflozin was associated with an 81% reduction in PC-AKI risk (HR 0.81,95% CI: 0.69-0.95, p=0.01) after adjustment for covariates 2
• Patients on dapagliflozin demonstrated better preservation of renal function at 48 and 72 hours post-procedure, with higher eGFR and lower serum creatinine and cystatin C levels 2

Cardiovascular Benefits in High-Risk Populations

• Dapagliflozin reduces cardiovascular death and heart failure hospitalization in patients with established cardiovascular disease, which includes many patients undergoing coronary angiography 1, 3, 4
• The DECLARE-TIMI 58 trial demonstrated consistent benefits for CV death/heart failure hospitalization regardless of peripheral artery disease status, a common comorbidity in patients requiring angiography 4

Important Caveats and Clinical Considerations

Metformin Management (Not Dapagliflozin)

• The 2019 ESC guidelines specifically recommend checking renal function if patients have taken metformin immediately before angiography and withholding metformin if renal function deteriorates 1
• This metformin recommendation should not be confused with SGLT2 inhibitor management, which has different perioperative considerations 1

When to Actually Stop Dapagliflozin

• Only stop for scheduled CABG surgery (3 days prior) 1
• Do not stop for diagnostic angiography, even in patients with multiple cardiovascular risk factors 1
• Do not stop for PCI procedures 1

Monitoring Considerations

• While dapagliflozin can be continued, ensure adequate hydration status before and after contrast administration 1
• Monitor for volume depletion, particularly in patients on concurrent diuretics 1
• Be aware that SGLT2 inhibitors may contribute to intravascular volume contraction; consider reducing diuretic doses if applicable 1

Risk of Ketoacidosis

• The risk of euglycemic diabetic ketoacidosis with SGLT2 inhibitors is primarily elevated in the perioperative surgical setting, not during diagnostic procedures 1
• For elective surgery including CABG, the 3-day discontinuation period allows for adequate drug clearance to minimize this risk 1

Practical Algorithm

For patients on dapagliflozin scheduled for coronary procedures:

1. Diagnostic angiography only → Continue dapagliflozin 1, 2
2. PCI planned → Continue dapagliflozin 1
3. CABG scheduled → Stop dapagliflozin 3 days before surgery 1
4. Urgent/emergent CABG → Accept the incremental risk if surgery cannot be delayed 1

The evidence strongly supports continuing dapagliflozin through diagnostic coronary angiography, with potential renal protective benefits, while reserving discontinuation exclusively for scheduled surgical revascularization. 1, 2