Empagliflozin and Anesthesia: Perioperative Management
Empagliflozin (and all SGLT2 inhibitors) must be discontinued 3 to 4 days before scheduled surgery to reduce the risk of perioperative metabolic acidosis and ketoacidosis. 1
Timing of Discontinuation
- Empagliflozin should be stopped at least 3 days before any planned surgical procedure 1, 2
- This recommendation applies to canagliflozin and dapagliflozin as well (≥3 days), while ertugliflozin requires ≥4 days 1
- The discontinuation is specifically intended to prevent postoperative ketoacidosis, a serious complication that can occur even with normal blood glucose levels 1, 2
Rationale for Perioperative Discontinuation
The primary concern with continuing empagliflozin through the perioperative period is euglycemic diabetic ketoacidosis—a life-threatening condition that may present with blood glucose levels less than 250 mg/dL, making it difficult to recognize 2. Several factors converge during surgery to increase this risk:
- Reduced oral intake (fasting requirements, postoperative nausea) combined with empagliflozin's mechanism creates a perfect storm for ketoacidosis 2
- Surgical stress and anesthesia alter the balance between hepatic glucose production and peripheral glucose utilization 1
- Volume depletion from both the drug's diuretic effect and perioperative fluid restrictions increases metabolic complications 2
Additional Perioperative Considerations
Volume Status Management
Empagliflozin causes intravascular volume contraction through its diuretic and natriuretic effects 1, 2. Before surgery:
- Assess and correct volume status preoperatively if the patient has been taking empagliflozin 2
- Patients may be more susceptible to hypotension during anesthesia induction if volume depleted 2
- Consider that empagliflozin users may have reduced effective circulating volume even without obvious clinical signs 1
Acute Kidney Injury Risk
The perioperative period presents multiple risk factors for acute kidney injury that are amplified by SGLT2 inhibitor use 2:
- Hypovolemia, reduced oral intake, and fluid losses during surgery increase AKI risk 2
- Concomitant medications (diuretics, ACE inhibitors, ARBs, NSAIDs) further elevate this risk 2
- Empagliflozin increases serum creatinine and decreases eGFR, particularly in hypovolemic states 2
When to Resume Therapy
While the guidelines are clear about discontinuation timing, resumption should be individualized based on:
- Adequate oral intake restored and stable fluid balance 2
- No signs of volume depletion or acute kidney injury 2
- Normal postoperative recovery without complications requiring reduced oral intake 2
Special Populations Requiring Extra Caution
Elderly Patients
Older patients face heightened risks with empagliflozin in the perioperative setting 3, 4:
- Elderly and frail patients may develop clinically significant dehydration more readily 3
- A case report documented cardiac arrest in a 68-year-old patient with reduced food/fluid intake while on empagliflozin 4
- Careful assessment of hydration status is essential in patients over 60 years 3
Patients with Neurological Deficits
Patients with conditions affecting oral intake (stroke, altered mental status) require particular vigilance 4:
- Reduced ability to communicate thirst or maintain adequate hydration 4
- Neurological deficits combined with empagliflozin's effects can lead to severe dehydration 4
Common Pitfalls to Avoid
Do not assume normal glucose levels rule out ketoacidosis in postoperative patients who received empagliflozin perioperatively—euglycemic DKA can occur with glucose <250 mg/dL 2
Do not restart empagliflozin immediately postoperatively without ensuring adequate oral intake and stable volume status 2
Do not overlook volume status assessment in patients who were taking empagliflozin preoperatively, even if discontinued appropriately 2
Do not continue empagliflozin in patients with eGFR <45 mL/min/1.73 m², as efficacy is limited and risks are increased 2, 5
Cardiovascular Benefits Context
While empagliflozin provides significant cardiovascular benefits (38% reduction in CV death, 35% reduction in heart failure hospitalization) 1, these long-term benefits do not outweigh the acute perioperative risks of ketoacidosis and volume depletion. The 3-4 day interruption for surgery is a necessary safety measure that does not compromise the drug's overall therapeutic value 1.