Preoperative SGLT2i use does not raise DKA risk in emergency surgery

Editor’s Note

Preoperative use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) does not increase the risk of postoperative diabetic ketoacidosis (DKA) in patients undergoing emergency surgery, according to a study published February 19 in JAMA Surgery. These findings challenge the current FDA recommendation to withhold SGLT2i medications for at least three days before surgery due to concerns about perioperative DKA risk. 

The retrospective cohort analysis used data from the Merative MarketScan Commercial and Medicare Supplemental Databases, covering 34,671 patients with type 2 diabetes who underwent one of 13 emergency surgeries between 2016 and 2022. Emergency procedures were chosen because patients were unlikely to withhold their SGLT2i medications, enabling the risk of DKA to be assessed without preoperative medication adjustments, researchers write. Among the patients, 7.5% (2,607) were exposed to SGLT2i medications, while the remaining 92.5% (32,064) used other antidiabetic agents. The most common surgeries were laparoscopic cholecystectomy and transurethral procedures.

The primary outcome was the occurrence of DKA within 14 days after surgery. Initial unadjusted rates of DKA were 4.9% in the SGLT2i group and 3.5% in the non-SGLT2i group. After adjusting for demographic variables, diabetes severity, comorbidities, and type of surgery using targeted maximum likelihood estimation (TMLE), the adjusted incidence of DKA was 3.8% for SGLT2i users and 3.5% for non-users. The difference was statistically insignificant, with an average treatment effect (ATE) of 0.2% (95% CI −1.7% to 2.2%). The findings were consistent across multiple sensitivity analyses, researchers write.  Further research is needed to confirm these results in elective surgical populations and among patients using SGLT2i medications for heart failure or chronic kidney disease management.