Perioperative Management of Oral Hypoglycemic Agents

General Recommendations

The American Diabetes Association recommends that most oral hypoglycemic agents should be held on the morning of surgery, with the exception of SGLT2 inhibitors, which must be discontinued 3-4 days preoperatively to prevent life-threatening euglycemic diabetic ketoacidosis 1, 2
The American Diabetes Association provides explicit timing recommendations, which are reinforced by the Praxis Medical Insights synthesis of multiple guideline sources, with the strongest evidence supporting the 3-4 day discontinuation period for SGLT2 inhibitors 1, 2, 3

SGLT2 inhibitors, such as canagliflozin, dapagliflozin, and empagliflozin, should be discontinued 3-4 days before surgery to prevent the risk of euglycemic diabetic ketoacidosis, which can occur even with normal glucose levels 1, 2, 3
The risk of perioperative diabetic ketoacidosis is significantly higher in patients taking SGLT2 inhibitors, with a rate of 1.02 vs. 0.69 per 1000 patients 3
Postoperative ketoacidosis can occur even when patients have withheld SGLT2 inhibitors for >72 hours, requiring vigilance and careful monitoring 3

Metformin should be held on the day of surgery only, as current guidelines support a less restrictive approach than historically practiced 1, 2
All other oral hypoglycemic agents, including sulfonylureas, DPP-4 inhibitors, thiazolidinediones, and meglitinides, should be held on the morning of surgery 1, 2, 3

Blood glucose should be monitored at least every 2-4 hours while the patient is NPO, with a target range of 100-180 mg/dL perioperatively 1, 2
Short- or rapid-acting insulin should be dosed as needed to maintain the target blood glucose range 1, 2

Cessation of SGLT2 inhibitors may worsen heart failure in patients with heart failure, requiring careful risk-benefit assessment 3
Prevention strategies during discontinuation of SGLT2 inhibitors include maintaining adequate hydration, avoiding prolonged fasting periods, and considering glucose-containing IV fluids if prolonged fasting is unavoidable 3
SGLT2 inhibitors should not be restarted until the patient is clinically stable and has resumed a normal diet, typically 24-48 hours after surgery, and ensure capillary ketones are <0.6 mmol/L before restarting 3