Dapagliflozin Discontinuation Prior to Surgery in Patients with Impaired Renal Function
Dapagliflozin must be discontinued at least 3 days (≥72 hours) before scheduled surgery in patients with impaired renal function, and this recommendation applies regardless of renal function status. 1, 2
Primary Recommendation
The FDA-approved drug label explicitly states that dapagliflozin should be withheld for at least 3 days prior to major surgery or procedures associated with prolonged fasting. 2
The 2024 AHA/ACC/ACS perioperative guideline provides a Class 1 (strong) recommendation that SGLT2 inhibitors including dapagliflozin should be withheld for 3 to 4 days before surgery when feasible to reduce the risk of perioperative metabolic acidosis. 1
This 3-day minimum discontinuation period applies to canagliflozin, dapagliflozin, and empagliflozin specifically, while ertugliflozin requires ≥4 days. 1
Rationale for the 3-Day Window
The primary concern is prevention of euglycemic diabetic ketoacidosis (DKA), a potentially life-threatening complication that can occur perioperatively with SGLT2 inhibitors. 1
Dapagliflozin has a half-life of approximately 12.9 hours, and the 3-day discontinuation period allows for adequate drug clearance (approximately 5-6 half-lives) to minimize metabolic risk. 3
The American Diabetes Association and multiple cardiovascular societies have endorsed this 3-4 day discontinuation recommendation. 1
Special Considerations for Impaired Renal Function
Patients with severe renal impairment show higher systemic exposure to dapagliflozin, which theoretically could prolong drug effects. 3
However, the guideline recommendation of ≥3 days discontinuation remains consistent across all renal function categories, as the primary concern is metabolic acidosis risk rather than anticoagulation or bleeding. 1, 2
The initial transient decrease in eGFR seen with dapagliflozin typically returns to baseline within 2-4 weeks, but this does not alter the preoperative discontinuation timeline. 4, 5
Critical Pitfalls to Avoid
Do not confuse SGLT2 inhibitor management with anticoagulant management—the 3-day rule for dapagliflozin is based on metabolic acidosis risk, not bleeding risk. 1
Do not continue dapagliflozin through surgery even in patients with heart failure on guideline-directed medical therapy (GDMT)—the metabolic acidosis risk outweighs the temporary interruption of SGLT2 inhibition. 1
Ensure volume status is assessed and corrected before surgery, as SGLT2 inhibitors can contribute to intravascular volume contraction. 1