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CLINICIAN REFERENCE

SGLT2 inhibitors

The cited ADA 2026 and AHA/ACC 2024 guidance recommends interruption before scheduled surgery for at least 3 days with canagliflozin, dapagliflozin or empagliflozin, and at least 4 days with ertugliflozin. The treating team incorporates this recommendation into a written perioperative plan.

Why interruption matters

Perioperative ketoacidosis, including euglycaemic ketoacidosis, remains an important concern, particularly in nonelective surgery, prolonged fasting or acute illness. Because blood glucose may be normal or only mildly raised, the diagnosis can be delayed if ketones and acid-base status are not checked.

Non-diabetic indications

SGLT2 inhibitors are also prescribed for heart failure and chronic kidney disease in patients without diabetes. The perioperative ketoacidosis concern still applies, and these patients may not identify the medicine as a “diabetes tablet.”

Practical application

  • Review of the complete medicine list, including fixed-dose combinations, helps identify SGLT2 treatment early.
  • Written last-dose dates can help patients follow the agreed interruption plan.
  • When the recommended interval has not elapsed, the urgency of surgery and local pathway guide reassessment; elective rescheduling may be appropriate.
  • For urgent or emergency surgery after recent SGLT2 use, guidance supports withholding further doses and monitoring for ketoacidosis according to the clinical situation and local protocol.
  • Symptoms such as nausea, vomiting, abdominal pain, malaise or tachypnoea after surgery should prompt assessment for ketoacidosis even with near-normal glucose.

Restarting

Decisions about restarting treatment depend on clinical recovery, nutritional intake and resolution of ketosis risk. Communicating the restart plan to the patient and their usual prescriber, particularly for heart failure indications, helps avoid unintended long-term interruption.

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