Management of Sodium-Glucose Cotransporter 2 Inhibitors During the Perioperative Period: A Retrospective Comparative Study

SLR - November 2020 - Reisha R. Banzon

Reference: Ge V, Subramaniam A, Banakh I, Wang WC, Tiruvoipati R. Management of Sodium-Glucose Cotransporter 2 Inhibitors During the Perioperative Period: A Retrospective Comparative Study. J Perioper Pract. 2020 Sep 8:1750458920948693. 

Level of Evidence: Level III, Retrospective Comparative Study

Scientific Literature Review

Reviewed By: Reisha R. Banzon, DPM
Residency Program: Southern Arizona VA Health Care System – Tucson, AZ

Podiatric Relevance: Many of our patients needing surgical intervention have history of Diabetes. Because of this, proper perioperative management of diabetic medication is important to make sure the patient’s glycemic status is medically optimized as much as possible before surgery, as well as postoperatively to avoid complications. In March 2020, the Food and Drug Administration recommended stopping sodium-glucose cotransporter 2 inhibitors (SGLT2Is) at least three to four days before scheduled surgery to lessen the risk of developing of diabetic ketoacidosis (DKA). Similarly, Australian and New Zealand College of Anesthetists (ANZCA) 2018, also recommended discontinuation of SGLT2Is for at least three days perioperatively (two days prior to surgery and the day of surgery). However, such recommendations are based on case reports, small case series and from non-surgical patients. This article aims to assess the effect of withholding SGLT2Is per ANZCA 2018 guidelines and whether it is associated with reduction of adverse events. This article proposed that complication rates would be higher when SGLT2Is were not withheld during perioperative period. 

Methods: This was a single center, retrospective comparative study that evaluated n=82 eligible patients, divided into two groups; n=16 in SGLT2Is withheld as per guideline group and n=66 in SGLT2Is not withheld group between January 2015 to December 2018. Inclusion criteria includes, adults above the age of 18, admission to surgical ward, fasting for at least 6h, and documented administration or discontinuation of SGLT2Is during perioperative period per current guideline from ANZCA 2018. The primary outcome was composed of major postoperative complications’ including euglycemic diabetic ketoacidosis (eDKA), DKA, Acute Kidney Injury (AKI) and urosepsis. The secondary outcomes included comparisons of blood glucose levels (BGL) preoperatively and readmission rate to the hospital within 28 days of discharge after prior surgery.  

Results: Major postoperative complications was significantly higher in SGLT2Is withheld group compared to patients who continued SGLT2Is therapy. SGLT2Is withheld group had significantly higher rates of eDKA compared to patients who continued SGLT2Is therapy. Although there was an increased incidence in AKI incidence in SGLT2Is withheld group, it did not reach statistical significance. There was no significant difference in other outcomes assessed between the groups. BGL were comparable between both groups preoperatively, but SGLT2Is withheld group had higher day one and day two BGLs. Patients who were readmitted did not have complications that could be attributed to SGLT2Is.

Conclusions: The authors concluded that withholding SGLT2Is per ANZCA 2018 guidelines was associated with increased risk of major postoperative complications, more specifically eDKA, as well as reduced glycemic control. However, further studies are needed that focuses on surgical patients and perioperative management to assess the risk and benefits of current guidelines for SGLT2Is and whether withholding it results in overall improved clinical outcomes. This shows that even though guidelines exist, they must be used with caution.