Dapagliflozin Discontinuation Prior to Surgery

Primary Recommendation

• The American Heart Association, American College of Cardiology, and American College of Surgeons provide a Class 1 (strong) recommendation that SGLT2 inhibitors, including dapagliflozin, should be withheld for 3 to 4 days before surgery when feasible to reduce the risk of perioperative metabolic acidosis 1, 2
• Dapagliflozin should be discontinued at least 3 days (≥72 hours) before scheduled surgery in patients with impaired renal function, regardless of renal function status 1, 2
• The 3-day minimum discontinuation period applies to canagliflozin, dapagliflozin, and empagliflozin specifically, while ertugliflozin requires ≥4 days 1, 2

Rationale for the 3-Day Window

• The primary concern is prevention of euglycemic diabetic ketoacidosis (DKA), a potentially life-threatening complication that can occur perioperatively with SGLT2 inhibitors 1, 3
• The American Diabetes Association and multiple cardiovascular societies have endorsed this 3-4 day discontinuation recommendation 1

Special Considerations for Impaired Renal Function

• However, the guideline recommendation of ≥3 days discontinuation remains consistent across all renal function categories, as the primary concern is metabolic acidosis risk rather than anticoagulation or bleeding 1, 2

Critical Pitfalls to Avoid

• Do not confuse SGLT2 inhibitor management with anticoagulant management—the 3-day rule for dapagliflozin is based on metabolic acidosis risk, not bleeding risk 1, 2
• Do not continue dapagliflozin through surgery even in patients with heart failure on guideline-directed medical therapy (GDMT)—the metabolic acidosis risk outweighs the temporary interruption of SGLT2 inhibition 1
• Ensure volume status is assessed and corrected before surgery, as SGLT2 inhibitors can contribute to intravascular volume contraction 3