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Sodium-glucose co-transporter type-2 inhibitors: is the message getting through?

Last post 12 Feb 2019, 9:16 PM by Mike Nathanson. 1 replies.
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  •  22 Jan 2019, 10:34 AM 2717

    Sodium-glucose co-transporter type-2 inhibitors: is the message getting through?

    Last year, Milder et al. brought the emerging problem of peri-operative euglycaemic ketoacidosis associated with sodium-glucose co-transporter type-2 inhibitors (SGLT2s) to our attention [1]. Having seen the devastating consequences of this complication in cardiac surgical patients, we recently changed local guidelines for such patients and plan to do the same for all types of major surgery across the hospital. The key message is that SGLT2s should be withheld for at least three days prior to major surgery (and longer for those receiving a ketotic diet). When this is not possible, such as in the context of urgent or emergency surgery, blood ketones should be regularly monitored. 

    We were pleased to see SGLT2s mentioned in recent articles on preā€operative optimisation of the surgical patient with diabetes [2] and a review of best practice for patients undergoing emergency laparotomy [3]. That said, it is our impression that many clinicians remain unaware of the potential for peri-operative euglycaemic ketoacidosis in such patients, the clinical consequences, and how the diagnosis may be delayed or discounted.

    It is perhaps unfortunate that the peri-operative hazards of SGLT2s emerged so soon following the 2015 Association of Anaesthetists guideline on the management of the surgical patient with diabetes [4]. The authors of this guideline advise that SGLT2s should be continued until the morning of surgery, when half the usual dose should be taken. Given the majority of hospitals in the UK use such guidelines to inform local policy, and that reports of SGLT2 associated euglycaemic ketoacidosis in the peri-operative period continue to emerge [5], is it time to consider an expedited update?

    M. Charlesworth

    L. Feddy

    N. Wisely

    Wythenshawe Hospital

    Manchester, UK

    Email: mda05mc@gmail.com

    No external funding or conflict of interest. MC is Social Media Editor for Anaesthesia.



    1. Milder DA, Milder TY, Kam PCA. Sodium-glucose co-transporter type-2 inhibitors: pharmacology and peri-operative considerations. Anaesthesia 2018; 73: 1008–18.

    2. Levy N, Dhatariya K. Pre-operative optimisation of the surgical patient with diagnosed and undiagnosed diabetes: a practical review. Anaesthesia 2019; 74: 58–66.

    3. Poulton T, Murray D. Pre-optimisation of patients undergoing emergency laparotomy: a review of best practice. Anaesthesia 2019; 74: 100–7.

    4. Barker P, Creasey PE, Dhatariya K et al. Peri-operative management of the surgical patient with diabetes 2015. Anaesthesia 2015; 70: 1427–40.

    5. Pace DJ, Dukleska K, Phillips S, Gleason V, Yeo CJ. Euglycemic Diabetic Ketoacidosis Due to Sodium–Glucose Cotransporter 2 Inhibitor Use in Two Patients Undergoing Pancreatectomy. Journal of Pancreatic Cancer 2018; 4: 95–9.

  •  12 Feb 2019, 9:16 PM 2735 in reply to 2717

    Sodium-glucose co-transporter type-2 inhibitors: is the message getting through? A reply

    I thank Charlesworth et al. for their correspondence about the recent, and somewhat concerning, reports of the risks associated with the use of these drugs. As they correctly point out, the 2015 Association of Anaesthetists guidance is now out of date in this important respect. We intend to issue a correction in the next few days that will appear in Anaesthesia and on the Association's website and guidelines 'app'. This is a quicker way to 'correct' (or update) guidelines as a full review can take up to 12 months. The Assocation aims to update all its guidelines every five years, so this particular document will be due a comprehensive review in the next year or so.

    M. Nathanson

    Immediate Past Honorary Secretary,

    Association of Anaesthetists,

    Email: mike@nathanson.info

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