The peri-operative implications of sodium-glucose co-transporter 2 inhibitors: a narrative review

Introduction: Sodium-glucose co-transporter 2 inhibitors are a novel class of antihyperglycaemic drugs used in the management of type 2 diabetes, that improve glycaemic control, cardiovascular outcomes and promote weight loss. They are also approved for the treatment of heart failure and chronic kidney disease in patients with or without diabetes. This narrative review discusses the peri-operative effects and implications of sodium-glucose co-transporter 2 inhibitors and gives an overview of current evidence and existing peri-operative guidelines.

Methods: We conducted a literature review to identify peer-reviewed English language articles published since 2000, with further articles identified by reviewing the references of key papers.

Results: Peri-operative sodium-glucose cotransporter 2 inhibitor use carries a risk of euglycaemic ketoacidosis. Although clinically significant diabetic ketoacidosis remains a rare event, sodium-glucose co-transporter 2 inhibitors inhibitor-associated diabetic ketoacidosis has been observed across almost all surgical specialities. Ketoacidosis may present with any blood glucose level. Existing guidelines are inconsistent and may be a source of clinical confusion.

Discussion: Based on the half-life of sodium-glucose cotransporter 2 inhibitors, we recommend withholding treatment for 72 h before elective surgery (5 half-lives), with additional multidisciplinary input for specific procedures with dietary alterations and in patients with poorly controlled diabetes of cardiac/renal disease. In the event of emergency surgery or any surgery within 72 h of sodium-glucose cotransporter 2 inhibitor administration, we recommend pre-, intra- and postoperative blood ketone monitoring (6 hourly for 24 h post-surgery and until full oral diet is resumed). Sodium-glucose cotransporter 2 inhibitor treatment should only be resumed after resumption of full oral diet in the absence of ketosis.