Preoperative SGLT2 Inhibitor Use and Postoperative Diabetic Ketoacidosis.
Anjali A Dixit1, Brian T Bateman1,2, Mary T Hawn3
1Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California.
JAMA Surgery
|February 19, 2025
Summary
Preoperative use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in patients undergoing emergency surgery did not increase the risk of diabetic ketoacidosis. This finding suggests current guidelines for withholding SGLT2i medications before surgery may be reconsidered.
Area of Science:
- Endocrinology
- Surgical Care
- Pharmacovigilance
Background:
- Current US FDA guidance recommends withholding sodium-glucose cotransporter 2 inhibitors (SGLT2i) for 3 days before surgery due to case reports of postoperative diabetic ketoacidosis.
- Withholding SGLT2i medications preoperatively may have negative consequences for diabetic patients.
- A large-scale evaluation is needed to assess the risk of diabetic ketoacidosis associated with SGLT2i use in surgical patients.
Purpose of the Study:
- To estimate the association between preoperative SGLT2i medication use and the risk of postoperative diabetic ketoacidosis.
- To evaluate this risk in patients undergoing various emergency surgeries, assuming they may not be able to withhold medication as per current guidance.
Main Methods:
- Retrospective cohort study utilizing a nationwide sample of patients with type 2 diabetes aged 18 years or older.
- Included patients who underwent 1 of 13 emergency surgeries between January 1, 2016, and December 15, 2022.
- SGLT2i medication use was the exposure, and diabetic ketoacidosis within 0-14 days post-surgery was the primary outcome, defined by diagnosis codes.
Main Results:
- The study included 34,671 patients undergoing emergency surgery; 7.5% used SGLT2i medications.
- The incidence of diabetic ketoacidosis was 4.9% in the SGLT2i group and 3.5% in the unexposed group (unadjusted).
- After covariate adjustment, the incidence was 3.8% for SGLT2i users vs. 3.5% for non-users, with an average treatment effect of 0.2% (95% CI, -1.7% to 2.2%), indicating no significant increased risk.
Conclusions:
- Preoperative SGLT2i medication use was not associated with an increased risk of postoperative diabetic ketoacidosis in patients undergoing emergency surgery.
- These findings may support a reconsideration of current guidelines regarding the preoperative withholding of SGLT2i medications.
- Liberalizing these guidelines could potentially mitigate negative consequences for diabetic patients undergoing surgery.
Related Concept Videos
01:23Dipeptidyl Peptidase 4 Inhibitors
164
Dipeptidyl peptidase 4 (DPP-4) is a serine protease widely distributed in the body. It's involved in the inactivation of GLP-1 and GIP hormones, which are crucial for insulin regulation. DPP-4 inhibitors, such as sitagliptin (Januvia), saxagliptin (Onglyza), linagliptin (Tradjenta), alogliptin (Nesina), and vildagliptin (Galvus), help increase the proportion of active GLP-1, enhancing insulin secretion. These inhibitors work by competitively binding to DPP-4. This binding causes a...
164
01:26Oral Hypoglycemic Agents: Biguanides and Glitazones
158
Biguanides, particularly metformin (Glucophage), are insulin sensitizers that enhance glucose uptake, thereby reducing insulin resistance. Unlike sulfonylureas, metformin doesn't prompt insulin secretion, which helps to curb hypoglycemia risk. Metformin is beneficial in treating conditions like polycystic ovary syndrome due to its insulin-resistance reduction capability. The drug's primary action involves curtailing hepatic gluconeogenesis, a significant contributor to high blood...
158
01:06Oral Hypoglycemic Agents: Glinides
131
Repaglinide (Prandin) and Nateglinide (Starlix), known as glinides, are oral insulin secretagogues that stimulate insulin release from pancreatic β cells by closing the ATP-sensitive potassium channels (KATP channel). Repaglinide controls insulin release from pancreatic β cells by managing potassium efflux. It shares two binding sites with sulfonylureas and also has a unique site, indicating overlapping mechanisms of action. With a rapid onset and a 4-7 hour duration, it effectively...
131
01:22Diabetes Mellitus: Type 2 and Gestational
2.1K
Type 2 diabetes, characterized by insulin resistance, arises when the insulin receptors on cells lose responsiveness to insulin, diminishing the cell's capacity to take up glucose, resulting in elevated blood glucose levels. To receive a diagnosis of Type 2 diabetes, a series of blood glucose tests are necessary to assess whether the blood glucose falls within normal parameters. If the result is out of the normal range, a patient may be diagnosed as prediabetic or diabetic, depending on the...
2.1K
01:19Oral Hypoglycemic Agents: α-Glucosidase Inhibitors
144
α-glucosidase inhibitors, including acarbose (Precose), miglitol (Glyset), and voglibose (Voglib) (primarily available in Asia), are drugs that control blood sugar levels by delaying the digestion of starch and disaccharides. They achieve this by inhibiting α-glucosidase enzymes in the intestine, which slow the absorption of carbohydrates in the intestine, which in turn leads to a prolonged release of the glucoregulatory hormone GLP-1 from intestinal L-cells.
Acarbose and miglitol are...
Acarbose and miglitol are...
144
01:24Glucagon-like Receptor Agonists
291
Incretins include glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP), which stimulate insulin secretion post-meals. In type 2 diabetes, GIP's efficacy is reduced, making GLP-1 a viable drug target. GIP originates from preproGIP.
GLP-1, when administered in high doses intravenously, triggers insulin secretion, inhibits glucagon release, slows gastric emptying, reduces food intake, and restores normal insulin secretion. However, its rapid inactivation by...
GLP-1, when administered in high doses intravenously, triggers insulin secretion, inhibits glucagon release, slows gastric emptying, reduces food intake, and restores normal insulin secretion. However, its rapid inactivation by...
291