Perioperative Management of SGLT2 Inhibitors and Biguanides

SGLT2 Inhibitors

• The British guideline recommends withholding SGLT2 inhibitors on the day before and the day of surgery due to the risk of normal blood glucose ketosis (euDKA) 1, 2
• SGLT2 inhibitors increase the risk of euDKA by altering the insulin/glucagon ratio, which can lead to ketone production even with normal blood glucose levels 2, 3
• The American College of Cardiology recommends withholding SGLT2 inhibitors 3-4 days before scheduled surgery (canagliflozin, dapagliflozin, and empagliflozin ≥3 days before, and ertugliflozin ≥4 days before) 2
• The risk of ketosis is higher in emergency surgery compared to scheduled surgery (1.1% vs 0.17%) 2, 3

Biguanides (Metformin)

• No relevant facts to report, as all biguanide facts were associated with [ignore ref]

Risk Reduction Strategies

• Maintaining adequate hydration and avoiding prolonged fasting is important to reduce the risk of lactate and ketone production 2
• Monitoring blood glucose and ketone levels is crucial during the perioperative period to prevent and detect lactate and ketone production 2, 3
• Consider using glucose-containing intravenous fluids to reduce ketone production during unavoidable prolonged fasting 2
• Educate patients on the symptoms of lactate and ketone production (nausea, vomiting, abdominal pain, and general weakness) and instruct them to seek medical attention immediately if symptoms occur 3