How long should Jardiance (empagliflozin) be held before surgery?

Perioperative Management of Jardiance (Empagliflozin)

Jardiance (empagliflozin) should be discontinued at least 3 days before elective surgery to prevent the potentially life-threatening complication of euglycemic diabetic ketoacidosis (euDKA). 1

Recommended Timing for Discontinuation

• Stop empagliflozin ≥3 days before scheduled surgery according to American College of Cardiology/American Heart Association 2024 guidelines 2, 1, 3
• The American Heart Association specifically recommends 3-4 days of discontinuation before elective surgery, as the clinical effects of SGLT2 inhibitors persist beyond their plasma half-life 1
• UK guidelines suggest a less conservative approach of omitting SGLT2 inhibitors only the day before and day of the procedure, though this carries higher risk 1, 3

Why This Duration Matters

The 3-day minimum discontinuation period is critical because:

• SGLT2 inhibitors alter the insulin-glucagon ratio, decreasing insulin secretion and relatively increasing glucagon, creating a hormonal environment that promotes ketogenesis even with normal glucose levels 1
• Clinical effects continue for 3-4 days after discontinuation, well beyond the drug's plasma half-life 1
• Euglycemic DKA presents with blood glucose <250 mg/dL despite metabolic acidosis (pH <7.3), elevated ketones, and high anion gap—making it diagnostically challenging since glucose appears normal 1

Risk Stratification

The risk of perioperative ketoacidosis varies significantly:

• Emergency surgery: 1.1% incidence of perioperative ketoacidosis 1, 3
• Elective surgery: 0.17% incidence when properly managed 1, 3
• Overall risk of perioperative DKA is higher in SGLT2 inhibitor users (1.02 vs 0.69 per 1000 patients) 1

Special Considerations for Heart Failure Patients

This creates a clinical dilemma: cessation of SGLT2 inhibitors in patients receiving them for heart failure may be associated with worsening heart failure 1, 3. However:

• The ACC/AHA 2024 guidelines explicitly recommend withholding for 3-4 days before elective noncardiac surgery even in heart failure patients to reduce perioperative metabolic acidosis risk 1
• A case report documented postoperative ketoacidosis with hypoglycemia in a nondiabetic patient taking dapagliflozin for heart failure who continued the medication on the day of transcatheter aortic valve replacement 4
• The risk of euDKA outweighs the short-term risk of heart failure decompensation during the brief perioperative period 1

Risk Mitigation During the Holding Period

While empagliflozin is held:

• Maintain adequate hydration to reduce ketone production 1, 3
• Avoid prolonged fasting periods whenever possible 1, 3
• Consider glucose-containing IV fluids in cases of unavoidable prolonged fasting to mitigate ketone generation 1, 3
• Monitor glucose and ketone levels during the perioperative period 3

When to Resume After Surgery

• Restart empagliflozin once the patient is eating and drinking normally, typically 24-48 hours after surgery 1, 3
• Ensure capillary ketones are <0.6 mmol/L before restarting 1
• Do not restart until the patient is clinically stable and has resumed a normal diet 1
• Postoperative ketoacidosis can occur even when patients have withheld SGLT2 inhibitors for >72 hours, so vigilance is required 1

Common Pitfalls to Avoid

• Do not continue empagliflozin on the day of surgery, even for heart failure indications—this has resulted in documented cases of euDKA 4
• Do not assume normal glucose levels rule out DKA—euglycemic DKA is the hallmark complication of SGLT2 inhibitors 1
• Do not restart too early—wait until normal oral intake is established and ketones are low 1
• Do not use the less conservative UK approach (holding only 1 day before) for high-risk surgeries or patients with additional risk factors 1, 3