Preoperative use of sodium-glucose cotransporter 2 inhibitors in patients undergoing emergency surgery was not linked to a higher incidence of postoperative diabetic ketoacidosis, according to a recent study. 

Investigators conducted a retrospective cohort study to assess whether preoperative use of sodium-glucose cotransporter 2 (SGLT2) inhibitors was associated with an increased risk of postoperative diabetic ketoacidosis (DKA) in patients undergoing emergency surgery. In the study, published in JAMA Surgery, the investigators evaluated 34,671 patients with type 2 diabetes (T2D) who underwent one of 13 emergency surgical procedures between January 1, 2016, and December 15, 2022. Given that patients undergoing emergency surgery were unlikely to adhere to the recommended 3-day SGLT2 inhibitor withholding period, this study provided a unique opportunity to examine DKA risk without preoperative medication discontinuation. 

Using the Merative MarketScan Commercial and Medicare Supplemental Databases, the investigators, led by Anjali A. Dixit, MD, MPH, of the Department of Anesthesiology, Perioperative and Pain Medicine at the Stanford University School of Medicine, identified patients aged 18 years or older with T2D who underwent emergency surgery within 1 to 2 days following an emergency department visit. SGLT2 inhibitor exposure was defined as prescription fills with days-supply overlapping with the surgery date. The primary outcome of the study was postoperative DKA within 14 days, identified using diagnostic codes.

Among the cohort, 7.5% (n = 2,607) of the patients were exposed to SGLT2 inhibitors, while 92.5% (n = 32,064) of them were not. The most common procedures were laparoscopic cholecystectomy (n = 9,385) and transurethral interventions (n = 12,246). The unadjusted incidence of DKA was 4.9% (n = 127) in the SGLT2 inhibitor–exposed group vs 3.5% (n = 1,115) in the unexposed group. After adjusting for demographics, diabetes severity, comorbidities, and surgical type, the estimated incidence was 3.8% in the SGLT2 inhibitor group and 3.5% in the non–SGLT2 inhibitor group, with an average treatment effect of 0.2% (95% confidence interval = –1.7% to 2.2%), indicating no statistically significant difference. Sensitivity analyses, including alternative outcome definitions and subgroup restrictions, supported these findings.

The results suggested that preoperative SGLT2 inhibitor use was not associated with an increased risk of postoperative DKA in this population. Given the risks of perioperative hyperglycemia and surgical delays as a result of medication withholding, these findings indicated that current guidelines on preoperative SGLT2 inhibitor discontinuation may warrant reconsideration. Further research is needed to confirm these findings in elective surgical settings and among patients using SGLT2 inhibitors for non-T2D indications.

Full disclosures can be found in the published study.