Should I stop dapagliflozin (SGL‑2 inhibitor) before my upcoming surgery?

Yes, Stop Dapagliflozin at Least 3 Days Before Surgery

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

Timing of Discontinuation

• Stop dapagliflozin exactly 3 days before your scheduled procedure 1, 2
• This recommendation applies regardless of whether you have diabetes, heart failure, or chronic kidney disease 1, 2
• The FDA drug label explicitly states to "withhold dapagliflozin for at least 3 days, if possible, prior to major surgery or procedures associated with prolonged fasting" 3

Why This Matters: The Ketoacidosis Risk

• SGLT2 inhibitors like dapagliflozin significantly increase your risk of developing euglycemic ketoacidosis during and after surgery (1.02 vs 0.69 per 1000 patients; OR 1.48) 4
• This dangerous complication can occur even when your blood glucose levels appear normal (<200 mg/dL), which is why it's called "euglycemic" ketoacidosis 4, 5
• The drug alters your insulin/glucagon ratio to favor ketone production, and this effect persists even after stopping the medication 4
• Case reports document ketoacidosis occurring in non-diabetic patients taking dapagliflozin for heart failure who underwent surgery, including one 83-year-old woman who took it on the day of her procedure 5

Critical Warnings

• The risk exists even if you stop the medication >72 hours before surgery—the risk is a continuum, so stopping earlier is safer 4
• You can develop ketoacidosis even if you don't have diabetes; this has been documented in heart failure patients 4, 5
• Emergency surgery carries a much higher ketoacidosis risk (1.1%) compared to elective surgery (0.17%) 4
• Three cardiac surgery patients who stopped their SGLT2 inhibitors only 1-2 days preoperatively all developed euglycemic ketoacidosis on postoperative day 1 6

Special Considerations for Heart Failure Patients

• Even though you may be taking dapagliflozin for heart failure management, you must still stop it before surgery 1, 5
• The American Heart Association gives this a Class 1 (strongest) recommendation specifically for patients with heart failure undergoing surgery 1, 4
• Your other heart failure medications (ACE inhibitors, beta-blockers, mineralocorticoid antagonists) should generally be continued, but SGLT2 inhibitors are the exception 1, 4
• Patients with heart failure already have a 3-fold higher perioperative mortality risk (9.2-9.3% vs 2.9%), making metabolic complications even more dangerous 4

Preoperative Preparation (Starting 3 Days Before)

• Maintain adequate hydration to reduce ketosis risk 4
• Avoid prolonged fasting when possible 4
• Your surgical team should monitor capillary glucose and ketones perioperatively 4

When to Restart After Surgery

• Resume dapagliflozin once you are eating and drinking normally, typically 24-48 hours after surgery 4
• Do not delay restarting unnecessarily, as this may lead to decompensated heart failure in patients taking it for that indication 4
• Ensure adequate hemostasis has been achieved before restarting 4

What to Watch For Postoperatively

• Signs of ketoacidosis include nausea, vomiting, abdominal pain, and general weakness 4, 6
• These symptoms are non-specific and common after surgery, which is why ketoacidosis is often diagnosed late 6
• If you develop these symptoms, your medical team should check serum and urine ketones immediately, even if your blood glucose is normal 4, 6

Bottom Line

The evidence is unequivocal: stop dapagliflozin at least 3 days before surgery. This recommendation is endorsed by the American Heart Association, American College of Cardiology, American College of Surgeons, and the American Diabetes Association, and is mandated by the FDA drug label 1, 4, 2, 3. The risk of perioperative ketoacidosis—which can be life-threatening—far outweighs any temporary interruption in your chronic disease management.