BoardsBridgeSGLT2 Inhibitors in the Perioperative Period
Hold 3–4 days preop; euglycemic DKA risk persists — recognize anion-gap acidosis even with glucose <200 mg/dL
SGLT2 inhibitors (empagliflozin, dapagliflozin, canagliflozin, sotagliflozin) must be held 3–4 days before elective surgery to prevent euglycemic DKA — an anion-gap acidosis with glucose often <200 mg/dL that the anesthesiologist may be the first to detect.
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HEADLINE: Hold SGLT2i 3–4 days before elective noncardiac surgery (AHA/ACC 2024, COR 1, LOE C-LD)
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Key numbers
- Hold duration: 3–4 days before elective noncardiac surgery (AHA/ACC 2024 COR 1, LOE C-LD)
- Euglycemic DKA glucose: <200 mg/dL in 35% of SGLT2i cases (ADA 2024); ≤250 mg/dL in 71%
- DKA diagnostic threshold: glucose ≥200 mg/dL (11.1 mmol/L) — lowered from >250 mg/dL (ADA 2024)
- SGLT2i DKA in T1D: ~4% incidence; 5–17× higher than untreated T1D (ADA 2024)
- SGLT2i DKA in T2D: 0.6–4.9 events per 1000 patient-years (ADA 2024)
- Euglycemic DKA fluid: add D5–D10 to IV fluids at the same time as 0.9% NaCl (ADA 2024)
- SGLT2i renal/AKI benefit: 23% AKI reduction irrespective of diabetes status (KDIGO 2024); 43% in DAPA-CKD; 45% in EMPA-KIDNEY
Uri Rozen, MD — Licensed Physician, Israel
Source guidelines: AHA ACC Perioperative Cardiovascular 2024 · AHA ACC Perioperative Cardiovascular 2024 · ADA Hyperglycemic Crises 2024 · ADA Hyperglycemic Crises 2024
Re-review cadence: 12 months from reviewed date.
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Card ID: sglt2-perioperative · Path: aba.pharmacology.antidiabetic-medications.sglt2-perioperative