In an adult diabetic patient who is NPO for a percutaneous coronary intervention (PCI), should dapagliflozin be held, and when can it be safely resumed?

Dapagliflozin Management for NPO Patients Undergoing PCI

Hold dapagliflozin on the day of PCI when the patient is NPO, and resume it only after the patient has returned to normal oral intake and is clinically stable—typically 24-48 hours post-procedure.

Rationale for Holding Dapagliflozin

Dapagliflozin must be withheld in any clinical situation that predisposes patients to ketoacidosis, including fasting states and acute illness. 1 The FDA label explicitly states: "Withhold DAPAGLIFLOZIN TABLETS, if possible, in temporary clinical situations that could predispose patients to ketoacidosis. Resume DAPAGLIFLOZIN TABLETS when the patient is clinically stable and has resumed oral intake." 1

Key Risk Factors During NPO Status for PCI

• Reduced caloric intake and fasting are established precipitating conditions for SGLT2 inhibitor-associated ketoacidosis. 1
• Volume depletion risk is heightened during NPO status, particularly when combined with contrast dye exposure during PCI. Dapagliflozin causes intravascular volume depletion through osmotic diuresis, which can manifest as symptomatic hypotension or acute kidney injury. 1
• The combination of NPO status, procedural stress, and potential contrast-induced nephropathy creates a perfect storm for metabolic complications. 2

When to Resume Dapagliflozin Post-PCI

Resume dapagliflozin only after ALL of the following criteria are met:

• The patient has resumed normal oral intake (not just sips of water, but actual meals). 1
• The patient is clinically stable with no signs of volume depletion, hypotension, or acute kidney injury. 1
• Renal function has been reassessed and remains adequate (eGFR ≥45 mL/min/1.73 m²). 1
• No signs or symptoms of ketoacidosis are present (nausea, vomiting, abdominal pain, shortness of breath). 1

Practical Timeline

• For uncomplicated PCI with same-day or next-day discharge: Resume dapagliflozin 24-48 hours post-procedure once oral intake is established. 1
• For complicated PCI or prolonged NPO status: Delay resumption until the patient has been eating normally for at least 24 hours and volume status is optimized. 2

Critical Monitoring Points

Before resuming dapagliflozin, actively assess for ketoacidosis regardless of blood glucose levels. 1 SGLT2 inhibitors can cause euglycemic ketoacidosis where glucose levels may be below 250 mg/dL but ketoacidosis is still present. 1, 2

Warning Signs That Mandate Continued Holding

• Any signs of volume depletion: orthostatic hypotension, tachycardia, decreased urine output. 1
• Acute kidney injury: creatinine elevation >0.3 mg/dL from baseline or eGFR drop. 1
• Symptoms suggestive of ketoacidosis: nausea, vomiting, abdominal pain, malaise, shortness of breath—even with normal glucose. 1, 2
• Ongoing NPO status or inability to maintain oral intake. 1

Special Considerations for Post-PCI Patients

The post-PCI period carries additional metabolic stress that compounds SGLT2 inhibitor risks. 2 A case report documented euglycemic DKA with severe hypernatremia (corrected Na 163 mEq/L) when dapagliflozin was resumed on day 3 in a patient with acute illness and dietary restrictions. 2

Electrolyte Monitoring

• Check serum sodium and potassium before resuming dapagliflozin. SGLT2 inhibitor-associated ketoacidosis can be accompanied by hypernatremia and hypokalemia. 2
• Patients on loop diuretics (common in heart failure patients undergoing PCI) are at particularly high risk for volume depletion and electrolyte disturbances. 1

Common Pitfalls to Avoid

• Do not resume dapagliflozin simply because the patient is "off the table" or discharged from the hospital. The FDA label is explicit that resumption requires both clinical stability AND resumed oral intake. 1
• Do not rely on normal blood glucose levels to rule out ketoacidosis. Euglycemic DKA is a well-documented complication of SGLT2 inhibitors. 1, 2
• Do not forget that urinary glucose excretion persists for 3 days after stopping dapagliflozin, and ketoacidosis has been reported lasting up to 2 weeks after discontinuation. 1
• Do not resume dapagliflozin in patients with acute kidney injury or eGFR <45 mL/min/1.73 m². 1

Patient Education

Educate the patient to discontinue dapagliflozin and seek immediate medical attention if signs of ketoacidosis develop: nausea, vomiting, abdominal pain, generalized malaise, or shortness of breath. 1 This education is particularly important in the post-PCI period when patients may attribute these symptoms to the procedure itself rather than a metabolic emergency.