Euglycemic Diabetic Ketoacidosis and Its Prevention in Elective Surgical Patients Taking Sodium-Glucose Linked Transporter 2 Inhibitors: An International Perspective

Background

Sodium-glucose linked transporter 2 (SGLT-2) inhibitors are becoming ubiquitous in medical practice. While beneficial in many areas, they have been implicated in a number of cases of euglycemic diabetic ketoacidosis, a serious and potentially fatal complication, in surgical patients. Therefore, it is important for health professionals to have clear guidelines on how to avoid this. The purpose of this study was to collate and evaluate the available guidelines for the perioperative management of patients taking SGLT-2 inhibitors and to outline the pathophysiology of EDKA in surgical patients.

Methods

A review of the available guidelines was performed using databases from 2010 to 2024. Nine guidelines from across the world were identified and reviewed for specific recommendations related to preoperative withholding time, ketone monitoring, postoperative reintroduction of SGLT-2 inhibitors, and emergency surgery.

Results

The most commonly recommended preoperative withholding time was 4 days for ertugliflozin and 3 days for all other SGLT-2 inhibitors. Most guidelines recommended regular ketone monitoring, but only one presented a detailed strategy. Most guidelines had no recommendation on reintroduction of SGLT-2 inhibitors, but those that did suggested that this should only happen given normal serum ketones and oral intake. Most guidelines had no consideration for emergency surgery, but those that did advocated for immediate treatment cessation.

Conclusions

There was little consensus between the guidelines, suggesting that this is a poorly understood subject. There is clearly a need for dissemination of the pathophysiological basis for the correct management of surgical patients taking SGLT-2 inhibitors, to avoid EDKA.