Abstract
Background
Euglycemic diabetic ketoacidosis (DKA) is a potentially life-threatening adverse condition
associated with use of sodium–glucose cotransporter-2 inhibitors (SGLT2i). This risk
is further pronounced in the perioperative period. There is no consensus for when
SGLT2i should be held preoperatively, and recommendations from various organizations
have evolved from 1 day to 3 to 4 days in the latest American Diabetes Association
guidelines. Further study of patients with perioperative euglycemic DKA is required
to help clarify the optimal timing of preoperative discontinuation of SGLT2i agents.
Methods
In this retrospective, single-centre case series we examined 4 patients who developed
postoperative euglycemic DKA after coronary artery bypass grafting, 3 of whom underwent
semiurgent surgery. We characterized their clinical course, predisposing factors and
treatment characteristics.
Results
The SGLT2i were held for 1 to 5 days preoperatively, with times since last dose before
surgery being 54, 79, 80 and 151 hours. Surgery was semiurgent for 3 patients, and
elective for 1 patient. Three patients were diagnosed with euglycemic DKA within 24
hours after surgery. The fourth patient developed euglycemic DKA on postoperative
day 3 in the context of significant hypovolemia and exhibited potential signs of protracted
SGLT2i action at 7 days since the last dose.
Conclusions
The duration of SGLT2i action and risk for DKA is variable and complex. Providers
should hold SGLT2i at least 3 days before elective major surgery, with potentially
longer times in high-risk patients. Careful vigilance should be used for perioperative
DKA development in all patients recently exposed to SGLT2i.
Résumé
Introduction
L’acidocétose diabétique (ACD) euglycémique est une complication potentiellement mortelle
associée à l’utilisation des inhibiteurs du cotransporteur sodium-glucose de type
2 (iSGLT2). Ce risque est davantage prononcé durant la période périopératoire. Il
n’existe pas de consensus pour dire jusqu’à quel moment avant l’opération les iSGLT2
devraient être maintenus, mais dans les plus récentes lignes directrices de l’Association
américaine du diabète, les recommandations provenant des différentes organisations
sont passées de 1 jour à 3-4 jours. Une étude plus approfondie au sujet des patients
qui ont une ACD euglycémique en phase périopératoire est nécessaire pour mieux cerner
le moment optimal de l’interruption en phase préopératoire des iSGLT2.
Méthodes
Dans la présente série rétrospective unicentrique de cas, nous nous sommes penchés
sur 4 patients, qui avaient eu une ACD euglycémique en phase postopératoire après
un pontage aortocoronarien, dont 3 avaient subi une intervention chirurgicale semi-urgente.
Nous avons décrit l’évolution clinique des patients, les facteurs prédisposants et
les caractéristiques du traitement.
Résultats
Les iSGLT2 avaient été maintenus de 1 à 5 jours avant l’opération, soit des durées
depuis la dernière dose avant l’intervention chirurgicale de 54, 79, 80 et 151 heures.
Trois patients avaient subi une intervention chirurgicale semi-urgente, et 1 patient
avait eu une intervention chirurgicale non urgente. Trois patients avaient reçu un
diagnostic d’ACD euglycémique dans les 24 heures après l’intervention chirurgicale.
Le 4e patient avait eu une ACD euglycémique le 3e jour après l’opération dans le contexte d’une hypovolémie significative et avait
montré des signes potentiels d’action prolongée des iSGLT2 7 jours après la dernière
dose.
Conclusions
La durée d’action des iSGLT2 et le risque d’ACD sont variables et complexes. Les prestataires
de soins de santé devraient maintenir les iSGLT2 au plus tard 3 jours avant l’intervention
chirurgicale lourde non urgente et potentiellement des durées plus longues chez les
patients exposés à un risque élevé. On devrait faire preuve d’une grande vigilance
en présence d’ACD en phase périopératoire chez tous les patients récemment exposés
aux iSGLT2.
Keywords
Mots clés
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Article Info
Publication History
Published online: June 23, 2022
Accepted:
June 15,
2022
Received in revised form:
May 6,
2022
Received:
April 7,
2022
Publication stage
In Press Journal Pre-ProofIdentification
Copyright
© 2022 Canadian Diabetes Association.
