What are the recommendations for managing Jardiance (empagliflozin) in a patient with a history of pancreatic disease undergoing a Whipple procedure?

Managing Jardiance (Empagliflozin) in Patients Undergoing Whipple Procedure

Discontinue Jardiance temporarily before the Whipple procedure and do not restart until the patient has stable oral intake, normal renal function, and no risk factors for ketoacidosis or volume depletion.

Preoperative Management

Timing of Discontinuation

• Stop Jardiance at least 3-4 days before scheduled surgery to minimize perioperative risks of ketoacidosis, volume depletion, and acute kidney injury 1
• Assess volume status and renal function (eGFR) before the procedure, as the FDA mandates evaluation of renal function before initiating or continuing SGLT2 inhibitors 1

Key Preoperative Considerations

• Volume status assessment is critical in patients on Jardiance, particularly those who are elderly, have low systolic blood pressure, or are on concurrent diuretics 1
• The Whipple procedure itself carries significant fluid shifts and metabolic stress, making preoperative optimization essential 2
• Patients with pancreatic disease may already have compromised nutritional status, which compounds the volume depletion risk from SGLT2 inhibitors 2

Perioperative Risks Specific to Jardiance

Ketoacidosis Risk

• Euglycemic diabetic ketoacidosis (DKA) is a major concern with SGLT2 inhibitors during surgical stress, even with normal blood glucose levels 1
• The FDA warns that clinical situations with reduced oral intake or metabolic stress (such as major surgery) predispose to ketoacidosis 1
• The Whipple procedure involves significant surgical stress, altered gastrointestinal anatomy, and often delayed gastric emptying (10-25% of cases), all of which increase ketoacidosis risk 3

Acute Kidney Injury

• Temporarily discontinue Jardiance in settings of reduced oral intake or fluid losses, which are inevitable during and after pancreaticoduodenectomy 1
• The FDA requires discontinuation if eGFR falls persistently below 45 mL/min/1.73 m² 1
• Perioperative fluid management after Whipple aims for near-zero fluid balance to optimize outcomes, which may conflict with the volume requirements for safe SGLT2 inhibitor use 2

Hypotension

• The osmotic diuresis from Jardiance can cause volume depletion and hypotension, particularly problematic during major surgery 1
• Enhanced Recovery After Surgery (ERAS) protocols for pancreaticoduodenectomy emphasize careful fluid balance, making the additional diuretic effect of Jardiance undesirable 2

Postoperative Management

When to Consider Restarting

• Do not restart Jardiance until ALL of the following criteria are met:
  • Patient tolerates normal oral intake without nausea or vomiting 3
  • No delayed gastric emptying (DGE), which occurs in 10-25% of post-Whipple patients 3
  • Stable renal function with eGFR ≥45 mL/min/1.73 m² confirmed 1
  • Adequate volume status without hypotension 1
  • No signs of metabolic acidosis or ketoacidosis 1

Special Postoperative Considerations

• Most patients can tolerate normal oral intake soon after elective pancreaticoduodenectomy, but this varies significantly 3
• Patients with prolonged DGE may require nasojejunal feeding or parenteral nutrition, during which time Jardiance should remain discontinued 3
• Monitor for urinary tract infections and urosepsis, as SGLT2 inhibitors increase risk of genitourinary infections, and the FDA specifically warns about urosepsis and pyelonephritis 1

Glycemic Management Alternatives

• Consider insulin therapy perioperatively rather than restarting Jardiance early, as insulin resistance and hyperglycemia are strongly associated with postoperative morbidity after pancreaticoduodenectomy 2
• If the patient was on insulin secretagogues or insulin with Jardiance preoperatively, doses may need adjustment when Jardiance is held to prevent hypoglycemia 1
• New-onset diabetes occurs in approximately 36% of patients after Whipple procedure, requiring reassessment of all diabetes medications 4

Long-Term Considerations

Pancreatic Function Changes

• Exocrine insufficiency develops in 24-71% of patients after Whipple procedure, affecting nutrient absorption 4, 5
• Endocrine insufficiency (diabetes) develops in 12-36% of patients postoperatively who did not have it preoperatively 4, 5
• These functional changes may alter the risk-benefit profile of continuing Jardiance long-term

Monitoring After Restart

• If Jardiance is restarted weeks to months after surgery, monitor for increased LDL-C and treat appropriately 1
• Continue monitoring renal function regularly, as required by FDA labeling 1
• Assess for genital mycotic infections, which are more common with SGLT2 inhibitors 1

Critical Pitfalls to Avoid

• Never continue Jardiance through the perioperative period due to compounded risks of ketoacidosis, acute kidney injury, and volume depletion in the setting of major pancreatic surgery
• Do not restart too early before confirming stable oral intake and normal renal function, as delayed gastric emptying is common after Whipple 3
• Do not assume normal glucose levels exclude ketoacidosis in patients on SGLT2 inhibitors presenting with metabolic acidosis symptoms postoperatively 1