Preoperative SGLT2 Inhibitor Use Not Linked to Higher DKA Risk, Claims Research

"This finding indicates that the recommended 3-day preoperative withholding period for SGLT2i medications may not be necessary," the researchers wrote in JAMA Surgery.

The study states that case reports of postoperative diabetic ketoacidosis in patients using sodium-glucose cotransporter 2 inhibitors (SGLT2i) medications have led to the US Food and Drug Administration's recommendation to withhold these medications for at least three days before surgery. However, concerns about the potential negative consequences of preoperative medication withholding highlight the need for a large-scale evaluation of the risk of diabetic ketoacidosis in this population.

To address this, Anjali A. Dixit, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, and colleagues aimed to estimate the association between preoperative SGLT2i use and postoperative diabetic ketoacidosis in patients undergoing various emergency surgeries, where adherence to current withholding guidance is often not feasible.

For this purpose, the researchers conducted a retrospective cohort study among a nationwide sample of patients aged 18 years or older with type 2 diabetes, enrolled in commercial or Medicare fee-for-service insurance plans, who underwent one of 13 emergency surgeries between 2016 and 2022. Emergency surgeries were identified as performed on the same day or within one to two days after an emergency department claim.

The study analyzed data from November 2023 through December 2024 to assess the association between preoperative SGLT2i medication use and the risk of postoperative diabetic ketoacidosis, defined by diagnosis codes, within 14 days after surgery.

The study revealed the following findings:

• The study included 34,671 patients with type 2 diabetes who underwent emergency surgery, with a mean age of 63.9 years. Of these patients, 55.3% were female, and 44.7% were male.
• The most common surgeries were laparoscopic cholecystectomy (9,385 patients) and transurethral procedures (12,246 patients).
• 2,607 patients (7.5%) had used SGLT2i medications, while 32,064 patients (92.5%) had not.
• The unadjusted incidence of diabetic ketoacidosis was 4.9% in the SGLT2i-exposed group and 3.5% in the unexposed group.
• After adjusting for demographic characteristics, diabetes severity, comorbidities, and surgery type, the incidence of diabetic ketoacidosis was 3.8% in the SGLT2i-exposed group and 3.5% in the unexposed group.
• The average treatment effect (ATE) was 0.2%.
• Findings remained consistent across alternate analyses, including intensive care unit–level care as an outcome (ATE, −1.0%).

"The study found no increased risk of postoperative diabetic ketoacidosis in patients using SGLT2i medications before emergency surgery compared to non-users. These findings suggest that current preoperative withholding guidelines for SGLT2i medications may be reconsidered," the researchers concluded.

Reference:

Dixit AA, Bateman BT, Hawn MT, Odden MC, Sun EC. Preoperative SGLT2 Inhibitor Use and Postoperative Diabetic Ketoacidosis. JAMA Surg. Published online February 19, 2025. doi:10.1001/jamasurg.2024.7082