Discontinuation of Jardiance (Empagliflozin) Before Surgery
Jardiance (empagliflozin) must be discontinued 3-4 days before surgery to prevent life-threatening euglycemic diabetic ketoacidosis (euDKA). 1, 2
Timing of Discontinuation
Stop empagliflozin at least 3 days (≥72 hours) before elective surgery, with some guidelines recommending up to 4 days for certain SGLT2 inhibitors like ertugliflozin. 1, 2, 3
The 3-4 day window is necessary because the clinical effects of SGLT2 inhibitors persist beyond their plasma half-life, continuing to promote ketogenesis for several days after the last dose. 3
For emergency surgery, the risk of euDKA is significantly higher (1.1% vs 0.17% for elective surgery), requiring heightened vigilance and potentially prophylactic insulin and glucose infusion during the perioperative period. 3, 4
Rationale for Extended Discontinuation
The extended discontinuation period is critical because SGLT2 inhibitors like Jardiance cause euDKA through multiple mechanisms: 3
- Altered insulin-glucagon ratio that promotes ketogenesis despite normal glucose levels
- Continued renal glucose excretion leading to relative insulin deficiency
- Surgical stress and fasting that amplify ketone production
Euglycemic DKA presents with metabolic acidosis (pH <7.3), elevated ketones, and high anion gap despite blood glucose <250 mg/dL (often <14 mmol/L), making it diagnostically challenging. 5, 6, 7
Critical Clinical Pitfalls
Even 72+ hours of discontinuation does not guarantee complete protection, as case reports document euDKA occurring 5-7 days after the last dose, particularly in patients with hypovolemia or prolonged fasting. 6
Postoperative symptoms of euDKA (nausea, vomiting, tachypnea) are nonspecific and easily attributed to routine postoperative recovery, leading to delayed diagnosis. 5, 8
The risk is present in both diabetic and non-diabetic patients taking SGLT2 inhibitors for heart failure, as insufficient insulin reserves cannot prevent ketosis. 3
Risk Mitigation Strategies During Discontinuation
Maintain adequate hydration throughout the perioperative period. 2, 3
Consider glucose-containing IV fluids if prolonged fasting is unavoidable to mitigate ketone generation. 2, 3
Monitor blood glucose every 2-4 hours while NPO, targeting 100-180 mg/dL perioperatively. 1, 2
For emergency surgery when discontinuation is impossible, initiate insulin and glucose infusion at the start of surgery to prevent euDKA. 4
When to Restart Jardiance
Do not restart until the patient is clinically stable, eating and drinking normally (typically 24-48 hours postoperatively), and capillary ketones are <0.6 mmol/L. 2, 3
Ensure adequate hydration and provide written sick-day rules at discharge. 3
For patients with heart failure, recognize that discontinuation may worsen heart failure, requiring careful risk-benefit assessment, though perioperative euDKA prevention takes priority. 2, 3
Special Consideration for Heart Failure Patients
Patients taking Jardiance for heart failure face a clinical dilemma, as cessation may worsen cardiac function. 2, 3 However, the risk of life-threatening euDKA, which can trigger acute coronary syndrome and cardiac arrest (as documented in post-CABG patients), outweighs the temporary discontinuation risk. 7