Perioperative Management of Farxiga (Dapagliflozin)
Farxiga (dapagliflozin) should be withheld for at least 3 days prior to major surgery or procedures associated with prolonged fasting. 1
Specific Timing Recommendations
The FDA-approved drug label for dapagliflozin provides explicit guidance on perioperative management 1:
- Withhold for at least 3 days before major surgery or procedures with prolonged fasting
- Resume when the patient is clinically stable and has resumed oral intake 1
Rationale for Discontinuation
The primary concern is diabetic ketoacidosis (DKA) risk, not bleeding complications. SGLT2 inhibitors like Farxiga significantly increase the risk of ketoacidosis, particularly in surgical settings where precipitating factors converge 1:
- Volume depletion from fasting and surgical stress
- Reduced caloric intake perioperatively
- Potential under-insulinization
- Acute illness and metabolic stress 1
Importantly, urinary glucose excretion persists for 3 days after discontinuing dapagliflozin, and ketoacidosis has been reported to persist longer than typically expected—sometimes greater than 6 days and up to 2 weeks after SGLT2 inhibitor discontinuation 1.
Clinical Context Considerations
While the 2025 multidisciplinary consensus statement on GLP-1 receptor agonists and SGLT2 inhibitors acknowledges the complexity of perioperative management, it emphasizes that SGLT2 inhibitors like dapagliflozin have different concerns than GLP-1 agonists (which primarily affect gastric emptying) 2. The ketoacidosis risk with SGLT2 inhibitors is the dominant safety concern.
Resumption of Therapy
Resume dapagliflozin only when 1:
- The patient is clinically stable
- Oral intake has been resumed
- No signs of ketoacidosis are present
- Volume status has been assessed and corrected if needed
Critical Monitoring
If surgery cannot be delayed and dapagliflozin was recently administered 1:
- Assess for ketoacidosis regardless of blood glucose levels (may be <250 mg/dL)
- Monitor for signs of severe metabolic acidosis: nausea, vomiting, abdominal pain, generalized malaise, shortness of breath
- Consider ketone monitoring in high-risk patients
- Promptly evaluate and treat if ketoacidosis is suspected
Common Pitfall
Do not assume normal blood glucose excludes ketoacidosis. Euglycemic DKA is characteristic of SGLT2 inhibitor-associated ketoacidosis, with glucose levels often below 250 mg/dL at presentation 1. The persistent glucosuria from dapagliflozin can mask the severity of metabolic derangement.