Perioperative management of SGLT2 inhibitors: balancing euglycaemic ketoacidosis risk and cardiorenal benefits.

Abstract

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are established therapies for type 2 diabetes, heart failure, and chronic kidney disease, creating a perioperative need to balance prevention of euglycaemic diabetic ketoacidosis (euDKA) against cardiorenal protection. Fasting, surgical stress, infection, reduced carbohydrate intake, insulin dose reduction, and hypovolaemia can amplify glycosuria and ketogenesis and precipitate euDKA. Most guidelines recommend withholding SGLT2 inhibitors for 3-4 days before elective surgery, although recommendations vary by agent, procedure, fasting duration, diabetes status, and monitoring capacity. Emerging evidence indicates competing perioperative risks and benefits. Inadequate withholding and emergency surgery are associated with high-anion-gap metabolic acidosis and ketoacidosis, whereas observational studies associate preoperative use with lower risks of acute kidney injury and short-term mortality. Heart failure withdrawal studies further suggest that cardiovascular and volume-regulatory benefits may diminish rapidly after interruption. These findings challenge uniform withholding but do not support routine perioperative continuation. Management should be stratified by treatment indication, glycated haemoglobin, insulin dependence, hepatic and kidney function, infection and volume status, surgical urgency and invasiveness, expected fasting duration, and access to ketone and acid-base monitoring. Patients at high metabolic risk generally require an adequate preoperative withholding interval and intensified monitoring, whereas low-risk patients treated primarily for heart failure or chronic kidney disease require individualised multidisciplinary assessment. Future studies should define indication- and risk-based withholding and restart strategies and jointly evaluate euDKA, acute kidney injury, worsening heart failure, myocardial injury, mortality, and postoperative recovery.