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Perioperative SGLT2i — RACP Adult Medicine MCQ

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ModerateClinical PharmacologyPerioperative SGLT2iRACP Adult Medicine

A 65-year-old man with an ejection fraction of 35% is scheduled for elective knee replacement. His medications include sacubitril/valsartan, bisoprolol, spironolactone, and dapagliflozin. What is the critical perioperative medication adjustment?

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Correct answer: C — Withhold dapagliflozin 3 days before surgery; continue other cardiac medications

SGLT2 inhibitors should be withheld 3 days before elective surgery due to the risk of euglycaemic diabetic ketoacidosis (eDKA) in the fasting perioperative state. The mechanism involves continued ketogenesis despite fasting and reduced carbohydrate intake. Heart failure medications (sacubitril/valsartan, beta-blocker, MRA) should generally be continued perioperatively to avoid heart failure decompensation, with dose held on the morning of surgery if hypotension is a concern. The SGLT2i can be restarted when the patient is eating and drinking normally post-operatively.

Reference: ADS – 2024 – Perioperative SGLT2i Management; ANZCA – 2024