Perioperative Management of SGLT2 Inhibitors

Introduction to Perioperative Risks

The risk of perioperative diabetic ketoacidosis (DKA) in patients taking SGLT2 inhibitors is 48% higher than in those not taking these medications (1.02 vs. 0.69 per 1000 patients), and DKA can occur even with normal blood glucose levels (euglycemic DKA) 1

For elective surgery, withhold SGLT2 inhibitors at least 3 days before major surgery, and for minor or ambulatory surgery, withhold the day before and the day of surgery, as recommended by the American College of Surgeons 1, 2
Consider glucose-containing IV fluids during prolonged procedures to mitigate ketone generation, and monitor for signs of volume depletion and hypotension 1

Do not restart SGLT2 inhibitors for at least 48 hours after major surgery, and before restarting, ensure patient is eating and drinking normally, renal function is adequate (eGFR ≥45 mL/min/1.73m²), capillary ketones are <0.6 mmol/L, and no signs of acute kidney injury, as recommended by the American Diabetes Association and the European Society of Anesthesiology 1, 2

Inadequate pre-operative discontinuation of SGLT2 inhibitors can lead to ketoacidosis, even when withheld for >72 hours in some cases, and premature restart of SGLT2 inhibitors after surgery can precipitate complications, such as DKA or acute kidney injury 1, 2

Monitor for signs of metabolic acidosis regardless of blood glucose levels, and monitor ketones closely regardless of blood glucose levels, as recommended by the American Society of Anesthesiologists and the Society of Critical Care Medicine 1, 2
Be vigilant for signs of volume depletion or hypotension, and consider factors that may increase the risk of DKA and volume depletion, such as dehydration, reduced caloric intake during recovery, acute illness or surgical complications, and inadequate insulin dosing (if applicable) 2
The following table summarizes the recommendations for perioperative management of SGLT2 inhibitors:

Society	Recommendation
American College of Surgeons	Withhold SGLT2 inhibitors at least 3 days before major surgery
American Diabetes Association	Monitor for signs of DKA and consider ketone monitoring in high-risk patients
European Society of Anesthesiology	Assess renal function prior to resuming SGLT2 inhibitors
American Society of Anesthesiologists	Withhold SGLT2 inhibitors for a specific period before major surgery due to the risk of DKA and volume depletion concerns
Society of Critical Care Medicine	Monitor for complications, such as dehydration, reduced caloric intake during recovery, acute illness or surgical complications, and inadequate insulin dosing (if applicable)