Management of sodium–glucose cotransporter 2 inhibitors during the perioperative period: A retrospective comparative study

Abstract

Purpose Current guidelines recommend withholding sodium–glucose cotransporter 2 inhibitors perioperatively due to concerns of euglycaemic diabetic ketoacidosis. However, such guidelines are largely based on case reports and small case series, many extrapolated from non-surgical patients. The aim was to investigate whether withholding sodium–glucose cotransporter 2 inhibitors as per current perioperative guidelines was associated with a reduction in serious adverse events, including euglycaemic diabetic ketoacidosis. Methods Instances of perioperative management of sodium–glucose cotransporter 2 inhibitors, over a four-year period were classified into two categories: those where sodium–glucose cotransporter 2 inhibitors were withheld as per guidelines and those where sodium–glucose cotransporter 2 inhibitors were administered in the perioperative period. The primary outcome was ‘total major perioperative complications’: a composite of serious adverse events including euglycaemic diabetic ketoacidosis, diabetic ketoacidosis, acute kidney injury, urosepsis and death. Results Eighty-two instances in 64 patients were included. Withholding sodium–glucose cotransporter 2 inhibitors was associated with an increased incidence of total major perioperative complications and poorer glycaemic control postoperatively. Multivariable logistic regression analysis revealed that withholding sodium–glucose cotransporter 2 inhibitors perioperatively (OR = 13.15; 95% CI = 1.8–138.9) and preoperative urea (OR 1.85 (95% CI = 1.17–3.43) were independently associated with an increase in total major postoperative complications. Conclusion Withholding sodium–glucose cotransporter 2 inhibitors as per current guidelines was associated with an increase in postoperative complications and reduced glycaemic control.

Sodium‐glucose cotransport‐2 inhibitor induced ketoacidosis following coronary artery bypass surgery: implications for management

“…18 However, prolonged cessation of SGLT2i, especially when combined with metformin or a DPP-4 inhibitor in a co-formulated tablet, might adversely affect peri-operative glycaemic control with emerging evidence suggesting worse post-procedure hyperglycaemia in patients who withhold SGLT2i pre-operatively. 19 The limitations of the present study are the relatively small number of DKA events and the use of a single centre. There might have been miscoding of retrospective data, including the possibility that diabetes was missed or its type misclassified in the case of patients with latent autoimmune diabetes of adults or secondary diabetes.…”

“…The biological effects of SGLT2i might persist for a week after the last dose and so longer durations of pre‐operative cessation have been suggested 18 . However, prolonged cessation of SGLT2i, especially when combined with metformin or a DPP‐4 inhibitor in a co‐formulated tablet, might adversely affect peri‐operative glycaemic control with emerging evidence suggesting worse post‐procedure hyperglycaemia in patients who withhold SGLT2i pre‐operatively 19 …”