Sodium-glucose co-transporter 2 inhibitors

Sodium-glucose co-transporter 2 (SGLT2) inhibitors have been associated with the development of diabetic ketoacidosis (DKA) in patients with type 1 or type 2 diabetes. The perioperative period may confer a higher risk because it is a time of prolonged fasting and decreased carbohydrate intake. To minimise the risk of DKA developing, stop SGLT2 inhibitors preoperatively in patients undergoing the following procedures:

  • surgery and procedures requiring bowel preparation (including colonoscopy)—for detailed advice, see Management of adults with type 2 diabetes who require bowel preparation
  • surgery and procedures requiring 1 day or longer in hospital—stop SGLT2 inhibitors for at least 3 days (2 days before the procedure and the day of the procedure)
  • day procedures, including gastroscopy—stop SGLT2 inhibitors on the day of the procedure and minimise the duration of fasting before and after the procedure.

The patient should be informed of the risk of DKA and provided with a written plan for the periprocedural management of their SGLT2 inhibitor.

Note: Withhold SGLT2 inhibitors in patients undergoing surgery or a procedure, including day procedures such as colonoscopy or gastroscopy.

The strongest risk factors for developing diabetic ketoacidosis are: patient unwell, SGLT2 inhibitor not stopped before the procedure, HbA1c more than 9%, and blood ketone concentration more than 1.7 mmol/L. If any of these factors are present, seek expert advice on whether to proceed with the procedure and refer to the Australian Diabetes Society alert on Periprocedural Diabetic Ketoacidosis (DKA) with SGLT2 Inhibitor Use In People with Diabetes for more information.

Any patient taking an SGLT2 inhibitor who becomes unwell in the week following a procedure (ie has abdominal pain, nausea, vomiting, fatigue or metabolic acidosis) should have their blood ketone concentration checked, even if their blood glucose concentrations are not elevated and the SGLT2 inhibitor was withheld periprocedurally. Blood glucose concentration may not be elevated in DKA associated with SGLT2 inhibitors, and a negative urinary ketone result does not exclude DKA.

Note: Check blood ketone concentration in any patient who has taken an SGLT2 inhibitor and who becomes acutely unwell in the week following a procedure.

If the blood ketone concentration is more than 1.0 mmol/L, perform an urgent arterial or venous blood gas measurement to check the pH and base excess. A low (negative) base excess of less than –5 mmol/L indicates metabolic acidosis. See Diabetic ketoacidosis for information on management of DKA.

For information on restarting an SGLT2 inhibitor after a procedure, see Postprocedural management of adults with type 2 diabetes.

Alerts highlighting the periprocedural risk of DKA in patients taking an SGLT2 inhibitor have been issued by the Australian Diabetes Society (ADS) and the Australian Therapeutic Goods Administration (TGA). As more evidence becomes available, recommendations for periprocedural use of SGLT2 inhibitors may change.