How many days should dapagliflozin be held prior to surgery in a patient with potential impaired renal function?

Dapagliflozin Discontinuation Prior to Surgery

Dapagliflozin must be discontinued at least 3 days (≥72 hours) before scheduled surgery, regardless of renal function status. 1, 2

Primary Recommendation

• The FDA drug label explicitly states to withhold dapagliflozin for at least 3 days prior to major surgery or procedures associated with prolonged fasting. 2
• The American Heart Association, American College of Cardiology, and American College of Surgeons provide a Class 1 (strong) recommendation for a 3-4 day discontinuation period for all SGLT2 inhibitors including dapagliflozin. 1
• The American Diabetes Association endorses this 3-4 day discontinuation window across all clinical scenarios. 3, 1

Why Exactly 3 Days Minimum

• The primary concern is prevention of euglycemic diabetic ketoacidosis (DKA), a potentially life-threatening perioperative complication. 3, 1
• This metabolic acidosis risk exists even in patients without diabetes, as demonstrated by a case report of postoperative ketoacidosis with hypoglycemia in a nondiabetic patient taking dapagliflozin for heart failure who continued the medication on the day of surgery. 4
• The 3-day minimum applies specifically to dapagliflozin, canagliflozin, and empagliflozin, while ertugliflozin requires ≥4 days. 1

Special Considerations for Impaired Renal Function

• The 3-day discontinuation period remains consistent across all renal function categories, including patients with impaired renal function. 1
• While dapagliflozin's glucose-lowering effect is minimal at eGFR <45 mL/min/1.73 m², the metabolic acidosis risk persists regardless of kidney function. 3
• The recommendation is based on metabolic acidosis prevention, not on drug clearance kinetics or bleeding risk. 1

Critical Pitfalls to Avoid

• Do not continue dapagliflozin through surgery even in patients with heart failure on guideline-directed medical therapy—the metabolic acidosis risk outweighs any temporary interruption of SGLT2 inhibition. 1
• Do not confuse SGLT2 inhibitor perioperative management with anticoagulant management—the 3-day rule is based on DKA risk, not bleeding or thrombotic concerns. 1
• Assess and correct volume status before surgery, as SGLT2 inhibitors cause intravascular volume contraction that can compound perioperative hemodynamic instability. 3, 1
• Be aware that euglycemic DKA can present atypically with normal or near-normal glucose levels, making clinical suspicion essential in the perioperative period. 3

Additional Perioperative Considerations

• Discontinue dapagliflozin during critical illness or prolonged fasting beyond scheduled surgery. 3
• Implement sick-day planning protocols to mitigate DKA risk in the perioperative period. 3
• Monitor for signs of DKA promptly if suspected postoperatively, and treat aggressively. 3