The Good, the Bad, and the Ugly: Sodium–Glucose Cotransporter-2 Inhibitors (Gliflozins) and Perioperative Diabetes

Kerridge, Ross; Whyte, Ian M.; Prior, F.N.; Luu, Judy; Story, David A

doi:10.1177/0310057x1804600202

Cited by 12 publications

(16 citation statements)

References 23 publications

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“…48 Based on the terminal half-life of 11e13 h, 48 h or even longer interruption has been recommended by recent editorials. 49 Yet, there are no consensus guidelines in this regard with some sources suggesting withholding for 5e7 days before major surgery 39 and up to 2 weeks for bariatric procedures when VLCD is introduced 1e2 weeks before operation. 43 We have earlier suggested a nuanced approach (The Queen Elizabeth Hospital regime; Adelaide, Australia) contemplating patient and surgical factors in managing these agents perioperatively.…”

Section: Discussionmentioning

confidence: 99%

Perioperative diabetic ketoacidosis associated with sodium-glucose co-transporter-2 inhibitors: a systematic review

Thiruvenkatarajan

Meyer

Nanjappa

et al. 2019

British Journal of Anaesthesia

119

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Background: Perioperative diabetic ketoacidosis (DKA) with near-normal blood glucose concentrations, termed euglycaemic ketoacidosis (EDKA), is an adverse effect associated with sodium-glucose co-transporter-2 inhibitors (SGLT2i). Guidelines are still evolving concerning the perioperative management of patients on SGLT2i. We performed a systematic review of published reports of DKA from SGLT2i in the surgical setting to understand better the clinical presentation and characteristics of SGLT2i-associated DKA. Methods: We searched PubMed, Embase, and ProQuest for reports of perioperative DKA involving SGLT2i up to January 2019. Results: Forty-two reports of EDKA and five cases of hyperglycaemic diabetic ketoacidosis (HDKA) were identified from 33 publications. Canagliflozin was implicated in 26 cases. Presentation time varied from a few hours up to 6 weeks after operation. Precipitating factors may include diabetes medication changes, diet modifications, and intercurrent illnesses. There were 13 cases (12 EDKA and one HDKA) of bariatric surgery, 10 of them noted very-low-calorie diet regimes as a precipitating factor. No precise association between interruption of SGLT2i and the occurrence of DKA could be identified. Seven patients required mechanical ventilation, and acute kidney injury was noted in five. Five cases needed imaging to rule out anastomotic leak and pulmonary embolism, all of them revealed negative findings. Outcome data were available in 32 cases, all of them recovered completely. Conclusions: EDKA is likely to be under-recognised because of its atypical presentation and may delay the diagnosis. Understanding this clinical entity, vigilance towards monitoring plasma/capillary ketones helps in early identification and assists in the management.

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Section: Discussionmentioning

confidence: 99%

Perioperative diabetic ketoacidosis associated with sodium-glucose co-transporter-2 inhibitors: a systematic review

Thiruvenkatarajan

Meyer

Nanjappa

et al. 2019

British Journal of Anaesthesia

119

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“…Because the average half-life for SGLT-2 inhibitors is about 12.5 hours, it is reasonable to withhold these medications for 3 days before major surgery to ensure that the drug is no longer having a metabolic effect. [25][26][27] The US Food and Drug Administration updated the SGLT-2 inhibitor prescribing information in March 2020 to recommend stopping canagliflozin, dapagliflozin, and empagliflozin at least 3 days before surgery and ertugliflozin at least 4 days before surgery. 28 Sodium-glucose cotransporter 2 inhibitors can be restarted once normal oral intake is resumed and the acute-phase response of surgery has resolved.…”

Section: Preoperative Management Of Noninsulin Diabetic Medicationsmentioning

confidence: 99%

“…28 Sodium-glucose cotransporter 2 inhibitors can be restarted once normal oral intake is resumed and the acute-phase response of surgery has resolved. 26 These medications serve to reduce long-term diabetes and cardiovascular complications, and so they do not need to be resumed immediately, especially after major surgery.…”

Section: Preoperative Management Of Noninsulin Diabetic Medicationsmentioning

confidence: 99%

Perioperative Evaluation and Management of Endocrine Disorders

Himes

Ganesh

Wight

et al. 2020

Mayo Clinic Proceedings

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“…However, it is linked with genitourinary infections and diabetic ketoacidosis (DKA) especially euglycemic DKA [1,[30][31]. The occurrence of euglycemic DKA is likely to increase in the peri -and postoperative period if they are not stopped perioperatively or restarted very soon postoperatively [32][33][34][35]. The awareness of a risk of developing euglycemic is very important to those who undergo surgery and a very high index of suspicion should be present not to miss it [1].…”

Section: Sodium-glucose Co-transporters 2 (Sglt2) Inhibitorsmentioning

confidence: 99%

“…At present, there is no agreement on the withholding of SGLT2 inhibitors before surgery but the general strategy is to stop them before 24-72 hours or even longer [1,[34][35]. Their use is associated with low risk of hypoglycemia and to stick or discontinue with it perioperatively is unlikely to produce any significant complications and either strategy is acceptable [1].…”

Section: Sodium-glucose Co-transporters 2 (Sglt2) Inhibitorsmentioning

confidence: 99%

Insight Into the Perioperative Management of Type 2 Diabetes

Zaidi¹,

Khan²,

Razak³

et al. 2020

Cureus

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Diabetic people are at risk of developing acute complications when exposed to stress. Surgery brings a stressful period when the patient is exposed not only to surgical stress but also the effects of medications used during that particular period. The patient's comorbidities can influence the perioperative management of diabetes. Poorly controlled diabetes can complicate the hospital course. The literature was searched through PubMed and the articles of the last 5 years, from 2014 to 2019, were looked into. The studies available as a free text, in the English language and related to humans, were included. Inclusion criteria also included adults with type 2 diabetes undergoing surgery. The perioperative management of diabetes is a challenging one. Apart from the diabetes control; comorbidities, general health, intake, and interaction of medications both anti-diabetic and non-diabetic, type and duration of surgery, are some of the factors that influence the outcome of the surgery. With a variety of options available to manage diabetes currently, it is important to have a good insight into their effects to prevent complications to occur and ensure safe discharge from the hospital. The good control of diabetes is essential in bringing favorable outcomes. The perioperative management of diabetes should be individualized. Oral anti-hyperglycemic medications, other than sulfonylureas and SGLT2 inhibitors, provide a reasonable alternative to insulin and can be continued safely perioperatively depending upon the type of surgery and the patient is expected to resume oral intake soon postoperatively.

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The Good, the Bad, and the Ugly: Sodium–Glucose Cotransporter-2 Inhibitors (Gliflozins) and Perioperative Diabetes

Cited by 12 publications

References 23 publications

Perioperative diabetic ketoacidosis associated with sodium-glucose co-transporter-2 inhibitors: a systematic review

Perioperative diabetic ketoacidosis associated with sodium-glucose co-transporter-2 inhibitors: a systematic review

Perioperative Evaluation and Management of Endocrine Disorders

Insight Into the Perioperative Management of Type 2 Diabetes

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