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Why SGLT2 inhibitors should be stopped before surgery

Case study shows continuing medication until surgery can lead to euglycemic diabetic ketoacidosis


Several cases of euglycemic diabetic ketoacidosis (eDKA) have been reported in patients taking sodium-glucose cotransporter 2 (SGLT2) inhibitors since the US Food and Drug Administration (FDA) approved the medication for type 2 diabetes.

Two women sitting and one-woman standing side-by-side and smiling
(From left to right): Charity Tan, nurse practitioner with inpatient glycemic team; Deborah Plante, director of inpatient glycemic team; and Berit Bagley, diabetes nurse specialist.

Patients most at risk of developing eDKA with SGLT2 inhibitors are those who had a recent surgery, acute medical illness or relative insulin deficiency. As a result of the reports, the American Diabetes Association Standards of Care recommends most SGLT2 inhibitors be stopped three days before a scheduled surgery.

To highlight the need for health care professionals to be more vigilant to this complication, UC Davis Health endocrinology team members wrote a case study, published by the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network (PSNet).

"Studies have shown that patients with diabetes mellitus on any SGLT2i have an increased risk of developing eDKA, especially after undergoing a surgical procedure,” said Deborah Kathleen Plante, author of the paper and professor of endocrinology at UC Davis Health. “Therefore, health care professionals need to be vigilant in educational and preventive measures.”

Connection between SGLT2 inhibitors and eDKA

As an increasing number of patients are being treating for diabetes, cardiovascular disease and renal disease, the use of SGLT2 inhibitors – a class of drugs that lowers blood sugar levels by preventing the kidneys from reabsorbing sugar – has risen dramatically in the past few years.

While these medications are effective, they can cause adverse events including eDKA – a rare, acute, life-threatening emergency that is characterized by euglycemia, metabolic acidosis and ketoacidosis. Diagnosing eDKA is challenging and often delayed or even missed, due to the lack of severe hyperglycemia.

UC Davis Health patient case study

The patient with well-controlled type 2 diabetes underwent elective implantation of a cardiac resynchronization and defibrillator device (CRT-D).

Following the successful procedure, the patient was discharged the next day with instructions to resume all his prior medications, including his SGLT2 inhibitor. But the next day he returned to the Emergency Department with severe nausea, vomiting and abdominal pain. He was diagnosed with eDKA and transferred to the intensive care unit for insulin infusion. However, a non-ST-elevation myocardial infarction complicated his recovery by requiring additional medical management.

Upon further questioning, his care team discovered that the patient had not been instructed to stop taking his SGLT2 inhibitor three days before the implant surgery. Instead, he was told not to take it the day of the procedure, then resume all medications after discharge.

“With specific reference to this case, it is important for health systems to work with patients regarding appropriate times to stop or hold certain medications,” Plante explained. “Their communications must involve a comprehensive and coordinated effort to ensure that patients receive the most appropriate and safe medication regimens.”

Recommended approach to improving patient safety

One of the responsibilities of the inpatient glycemic team is to align UC Davis Medical Center with current American Diabetes Association standards of care for inpatient diabetes management and best practices for glycemic management in all areas of the hospital.

The team makes the following recommendations to minimize risks when managing medication transitions in the periprocedural period:

  • Remember SSTOP (Stop SGLT2 inhibitors Three days bef-O-re Procedures)
  • Educate clinical staff to recognize the signs and symptoms of eDKA
  • Screen early for urine or serum ketones in patients with unplanned procedures or high risk for eDKA
  • Standardize and optimize medication adjustment recommendations before and after procedures and operations so they can be implemented by any staff member
  • Utilize information systems to “push” reminders (or cautions) to patients regarding appropriate times to stop or hold certain medications

In addition to Plante, research co-authors of the case study include Berit Bagley, advanced practice nurse specialist and Charity Tan, nurse practitioner, from the UC Davis Health inpatient glycemic team.