Why should Jardiance (empagliflozin) be stopped before procedures in patients with type 2 diabetes and potentially impaired renal function?

Why Jardiance Must Be Stopped Before Procedures

Jardiance (empagliflozin) must be discontinued 3-4 days before scheduled surgery or procedures requiring prolonged fasting to prevent life-threatening diabetic ketoacidosis (DKA), which can occur even with normal blood glucose levels. 1, 2

Primary Risk: Euglycemic Diabetic Ketoacidosis

The most critical reason for stopping Jardiance before procedures is the risk of euglycemic DKA—a potentially fatal complication that can develop even when blood glucose appears normal (often <250 mg/dL). 2

Key characteristics of procedure-related DKA risk:

• Fatal cases have been reported in patients taking empagliflozin 2
• Presents with dehydration and severe metabolic acidosis: nausea, vomiting, abdominal pain, generalized malaise, and shortness of breath 2
• Blood glucose levels are often below 250 mg/dL, delaying recognition and treatment 2
• Surgical procedures are a specific predisposing risk factor for DKA 3

Specific Timing Recommendations

Discontinue empagliflozin 3-4 days before scheduled surgery. 1, 3 This timing allows the drug to clear from the system and reduces the metabolic stress that predisposes to ketoacidosis during the perioperative period.

Additional Perioperative Risks

Beyond DKA, stopping Jardiance before procedures addresses several other serious complications:

Volume Depletion and Hypotension

• Empagliflozin causes intravascular volume contraction through its diuretic effect 2
• Fasting and reduced oral intake during procedures compound this volume depletion 2
• Elderly patients, those on diuretics, and patients with low systolic blood pressure are at particularly high risk 2, 3

Acute Kidney Injury

• Empagliflozin can cause renal impairment, with postmarketing reports of acute kidney injury requiring hospitalization and dialysis 2
• Reduced oral intake during procedures (fasting) is a specific trigger for acute kidney injury 2
• The drug should be temporarily discontinued in any setting of reduced oral intake or fluid losses 2

Clinical Algorithm for Perioperative Management

Before surgery:

1. Stop empagliflozin 3-4 days before scheduled procedures 1, 3
2. Assess and correct volume status before the procedure 2
3. Identify additional risk factors: insulin deficiency, reduced caloric intake, acute illness, alcohol use 2

During the perioperative period:

• Monitor for signs of ketoacidosis regardless of blood glucose levels 2
• Assess for dehydration and metabolic acidosis 2
• Maintain adequate hydration and monitor renal function 2

After surgery:

• Do not restart empagliflozin until the patient has recovered from acute illness 4
• Ensure normal oral intake is re-established before restarting 4
• Verify adequate renal function before resuming therapy 2

Common Pitfalls to Avoid

Never continue empagliflozin through surgery assuming normal glucose levels indicate safety. Euglycemic DKA can occur with blood glucose <250 mg/dL, and the presenting symptoms (nausea, vomiting, abdominal pain) may be attributed to postoperative recovery rather than recognized as ketoacidosis. 2

Do not restart empagliflozin too quickly postoperatively. Wait until the patient has fully recovered, is eating and drinking normally, and has stable renal function. 4, 2

Maintain at least low-dose insulin in insulin-requiring patients even when empagliflozin is held. Complete insulin cessation combined with SGLT2 inhibitor use significantly elevates ketoacidosis risk. 4

Special Considerations for Emergency Surgery

For emergency procedures where 3-4 days of discontinuation is not possible:

• Immediately discontinue empagliflozin 1
• Establish glucose infusion if the patient remains fasting 1
• Monitor closely for ketoacidosis with blood or urine ketone testing 4
• Treat any volume depletion aggressively 2