When should a patient with stable renal function and no significant comorbidities discontinue dapagliflozin (SGLT2 inhibitor) prior to undergoing laparoscopic surgery?

When to Discontinue Dapagliflozin Prior to Surgery

Dapagliflozin should be discontinued at least 3 days (≥72 hours) before scheduled surgery, including laparoscopic procedures, to reduce the risk of perioperative metabolic acidosis and euglycemic diabetic ketoacidosis. 1, 2, 3

Primary Recommendation

• The 2024 AHA/ACC/ACS guideline provides a Class 1 (strong) recommendation that SGLT2 inhibitors, including dapagliflozin, must be withheld for at least 3 days before surgery when feasible. 1

• The FDA drug label for dapagliflozin explicitly states: "Withhold DAPAGLIFLOZIN TABLETS for at least 3 days, if possible, prior to major surgery or procedures associated with prolonged fasting." 3

• This 3-day minimum applies specifically to dapagliflozin (as well as canagliflozin and empagliflozin), while ertugliflozin requires ≥4 days. 1, 2

Rationale: Prevention of Life-Threatening Ketoacidosis

• The primary concern driving this recommendation is prevention of euglycemic diabetic ketoacidosis (euDKA), a potentially fatal complication that can occur perioperatively even in patients without diabetes. 2, 3, 4

• Case reports document fatal ketoacidosis events in patients taking SGLT2 inhibitors perioperatively, including a nondiabetic 83-year-old woman with heart failure who took dapagliflozin on the day of transcatheter aortic valve replacement and developed postoperative ketoacidosis with hypoglycemia. 4

• Three patients who discontinued SGLT2 inhibitors only 1-2 days preoperatively (rather than the recommended 3 days) developed euDKA after cardiac surgery, presenting with metabolic acidosis (pH <7.3) despite relatively normal glucose levels (<14 mmol/L). 5

• Urinary glucose excretion from dapagliflozin persists for 3 days after discontinuation, and postmarketing reports document ketoacidosis lasting greater than 6 days and up to 2 weeks after SGLT2 inhibitor discontinuation. 3

Application to Your Clinical Scenario

• For a patient with stable renal function undergoing laparoscopic surgery, discontinue dapagliflozin at least 3 days (≥72 hours) before the procedure. 1, 3

• The 3-day discontinuation period applies regardless of renal function status—the guideline recommendation is consistent across all renal function categories because the primary concern is metabolic acidosis risk, not drug clearance. 2

• Laparoscopic surgery qualifies as a procedure requiring the 3-day discontinuation because it involves general anesthesia, fasting, and metabolic stress—all precipitating factors for ketoacidosis. 3

Critical Pitfalls to Avoid

• 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. 2, 4

• Do not confuse SGLT2 inhibitor management with anticoagulant management—the 3-day rule for dapagliflozin is based on metabolic acidosis risk, not bleeding risk. 2

• Do not assume that stopping dapagliflozin 1-2 days preoperatively is sufficient—case series demonstrate that this shorter interval still carries significant risk of euDKA. 5

• Ensure volume status is assessed and corrected before surgery, as SGLT2 inhibitors contribute to intravascular volume contraction. 2, 3

Postoperative Resumption

• Resume dapagliflozin only when the patient is clinically stable and has resumed oral intake. 3

• The FDA label specifically instructs to wait until clinical stability is achieved before restarting therapy. 3

Evidence Quality and Strength

• The 2024 AHA/ACC/ACS guideline represents the most recent and authoritative guidance, endorsed by the American Diabetes Association and multiple cardiovascular societies. 1, 2

• While one 2025 retrospective cohort study of emergency surgery patients found no increased risk of postoperative diabetic ketoacidosis with preoperative SGLT2i use (ATE 0.2%, 95% CI -1.7% to 2.2%), this study examined emergency surgery where medication withholding was not possible—a fundamentally different clinical scenario than elective laparoscopic surgery where the 3-day discontinuation is feasible. 6

• The guideline recommendation is based on pharmacokinetic data, case reports of fatal outcomes, and the principle of harm reduction in elective surgery where medication withholding is achievable. 1, 3, 4, 5