From the Guidelines
SGLT2 inhibitors should be discontinued 3–4 days before surgery. This recommendation is based on the most recent and highest quality study, which suggests that stopping these medications at least 72 hours prior to any surgical procedure can reduce the risk of perioperative metabolic acidosis and euglycemic diabetic ketoacidosis (euDKA) 1. The study, published in 2024, provides clear guidance on the management of SGLT2 inhibitors in the perioperative period, emphasizing the importance of withholding them for 3 to 4 days before surgery to minimize potential complications.
Some key points to consider when managing SGLT2 inhibitors in the perioperative period include:
- The risk of euDKA and metabolic acidosis associated with SGLT2 inhibitors during periods of fasting and stress, which are common in the surgical setting 1
- The potential for volume depletion and electrolyte imbalances due to increased urinary glucose excretion caused by SGLT2 inhibitors 1
- The persistence of metabolic effects of SGLT2 inhibitors for several days after discontinuation, highlighting the need for careful management in the perioperative period 1
It is essential to note that the specific withholding period may vary depending on the type of SGLT2 inhibitor, with canagliflozin, dapagliflozin, and empagliflozin typically stopped ≥3 days and ertugliflozin ≥4 days before scheduled surgery 1. Patients should resume their SGLT2 inhibitor only after they have fully recovered from surgery, are eating and drinking normally, and have stable kidney function, typically 1-3 days after an uncomplicated procedure or longer for major surgeries.
From the FDA Drug Label
Withhold DAPAGLIFLOZIN TABLETS for at least 3 days, if possible, prior to major surgery or procedures associated with prolonged fasting. Withhold INVOKANA at least 3 days, if possible, prior to surgery or procedures associated with prolonged fasting.
Hold SGLT2 inhibitors for at least 3 days prior to surgery, if possible, as recommended for both dapagliflozin 2 and canagliflozin 3. Resume the medication when the patient is clinically stable and has resumed oral intake.
From the Research
SGLT2 Inhibitors and Surgery
- There is no direct evidence in the provided studies regarding the specific duration to hold SGLT2 inhibitors prior to surgery.
- However, it is known that SGLT2 inhibitors can increase the risk of diabetic ketoacidosis, particularly in patients with type 1 diabetes or those undergoing surgery 4.
- The use of SGLT2 inhibitors may need to be temporarily discontinued before surgery to minimize the risk of complications, but the exact duration is not specified in the available studies.
- It is essential to consider the individual patient's condition, the type of surgery, and the anesthetic approach when deciding whether to hold SGLT2 inhibitors before surgery.
General Considerations for SGLT2 Inhibitors
- SGLT2 inhibitors are a class of medications used to treat type 2 diabetes by increasing urinary glucose excretion 5.
- They have been shown to be effective in reducing blood glucose levels, weight, and systolic blood pressure, with a low risk of hypoglycemia 5, 6.
- Common adverse effects of SGLT2 inhibitors include genital mycotic infections, increased urination, and volume depletion 7, 6.
- SGLT2 inhibitors have also been found to have cardiovascular and renal benefits, making them a valuable treatment option for patients with type 2 diabetes and cardiovascular or renal disease 8.