Resuming Farxiga After Spine Surgery
Farxiga (dapagliflozin) should be withheld for at least 3 days before spine surgery and can only be resumed once the patient is clinically stable, eating and drinking normally, and adequate surgical hemostasis is established—typically 24-48 hours postoperatively at the earliest. 1, 2
Preoperative Discontinuation Requirements
The FDA label explicitly states that dapagliflozin must be withheld for at least 3 days prior to major surgery or procedures associated with prolonged fasting to prevent the life-threatening complication of euglycemic diabetic ketoacidosis (euDKA) 2
The American College of Cardiology/American Heart Association guidelines recommend stopping dapagliflozin ≥3 days before scheduled surgery, with effects persisting beyond plasma half-life for 3-4 days after discontinuation 1
British guidelines suggest a less conservative approach (withholding the day before and day of surgery), but given the severity of euDKA risk, the more conservative 3-day approach is safer for major procedures like spine surgery 3
Critical Risk: Euglycemic Diabetic Ketoacidosis
SGLT2 inhibitors like Farxiga cause euDKA through altered insulin-glucagon ratios, leading to ketogenesis despite normal glucose levels (<250 mg/dL), presenting with metabolic acidosis (pH <7.3), elevated ketones, and high anion gap 1
Postoperative euDKA can occur even when patients discontinue dapagliflozin 48-72 hours before surgery, as demonstrated in cardiac surgery cases where patients developed fatal ketoacidosis despite appropriate preoperative cessation 4, 5
Urinary glucose excretion and ketone production can persist for 3 days after discontinuation, with some cases reporting glucosuria and ketonuria lasting up to 2 weeks post-discontinuation 2, 6
Emergency surgery carries significantly higher ketoacidosis risk (1.1%) compared to elective surgery (0.17%) 1, 3
Postoperative Resumption Criteria
Farxiga should only be restarted when ALL of the following conditions are met:
Patient is clinically stable and has resumed normal oral intake (usually 24-48 hours after surgery minimum) 1, 2
Adequate surgical hemostasis is established to prevent bleeding complications 1
Capillary ketones are <0.6 mmol/L before restarting therapy 1
Patient is adequately hydrated and not experiencing prolonged fasting 1, 3
Special Considerations for Spine Surgery
For spine surgery specifically, anticoagulation/antiplatelet management consensus recommends careful attention to hemostasis, with timing of medication resumption based on bleeding risk stratification 7
The combination of surgical stress, potential prolonged fasting, volume depletion from blood loss, and reduced mobility after spine surgery creates multiple risk factors for euDKA 1
Major surgical procedures trigger stronger stress responses, increasing euDKA risk beyond baseline 1
Critical Pitfalls to Avoid
Never restart Farxiga before adequate hemostasis is established or before the patient can tolerate oral intake 1, 2
Do not assume safety based solely on time elapsed since last dose—monitor for ketones even if >3 days have passed since discontinuation 6
Non-diabetic patients taking Farxiga for heart failure or chronic kidney disease are still at risk of euDKA, as they may lack sufficient insulin to prevent ketosis 1, 8
Provide written sick-day rules to patients at discharge, instructing them to seek immediate medical attention for symptoms of ketoacidosis (nausea, vomiting, abdominal pain, malaise, shortness of breath) 1, 2
Monitoring Requirements
Monitor blood glucose AND ketone levels during the perioperative period, as euDKA presents with normal or near-normal glucose (<250 mg/dL) 1, 3
Maintain adequate hydration and consider glucose-containing IV fluids if prolonged fasting is unavoidable 1, 3
Assess for signs of metabolic acidosis regardless of blood glucose levels in any patient with prior SGLT2 inhibitor use 2
Heart Failure Considerations
For patients taking Farxiga for heart failure indications, cessation may be associated with worsening heart failure, creating a clinical dilemma that requires careful risk-benefit assessment 9, 1
However, the risk of fatal euDKA outweighs the temporary discontinuation risk in the perioperative period 1, 5