Perioperative Management of Empagliflozin

Introduction to Perioperative Considerations

The American College of Cardiology recommends that empagliflozin be discontinued 3 to 4 days before scheduled surgery to reduce the risk of perioperative metabolic acidosis and ketoacidosis 1
Empagliflozin should be stopped at least 3 days before any planned surgical procedure, with this recommendation also applying to canagliflozin and dapagliflozin, while ertugliflozin requires ≥4 days 1
The discontinuation is specifically intended to prevent postoperative ketoacidosis, a serious complication that can occur even with normal blood glucose levels 2

Surgical stress and anesthesia alter the balance between hepatic glucose production and peripheral glucose utilization, increasing the risk of ketoacidosis 1
Empagliflozin causes intravascular volume contraction through its diuretic and natriuretic effects, and patients may be more susceptible to hypotension during anesthesia induction if volume depleted 3
Consider that empagliflozin users may have reduced effective circulating volume even without obvious clinical signs 3

Empagliflozin provides significant cardiovascular benefits, including a 38% reduction in CV death and a 35% reduction in heart failure hospitalization, as noted by the American College of Cardiology 4
These long-term benefits do not outweigh the acute perioperative risks of ketoacidosis and volume depletion, making the 3-4 day interruption for surgery a necessary safety measure that does not compromise the drug's overall therapeutic value 1