SGLT2i Associated Euglycemic Diabetic Ketoacidosis: Lessons from a Case Series of 4 Patients undergoing Coronary Artery Bypass Grafting Surgery

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      Euglycemic diabetic ketoacidosis (DKA) is a potentially life-threatening adverse condition associated with 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 3-4 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.


      This retrospective, single-centre case series examined four patients who developed postoperative euglycemic DKA after coronary artery bypass grafting, three of whom underwent semi-urgent surgeries. We characterized their clinical course, predisposing factors, and treatment characteristics.


      The SGLT2i were held for 1 to 5 days preoperatively, with times since last dose before surgery being 54 hours, 79 hours, 80 hours, and 151 hours. The surgeries were semi-urgent for three patients, and elective for one 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.


      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 employed for perioperative DKA development in all patients recently exposed to SGLT2i.

      Key Words


      CABG (coronary artery bypass grafting), CSICU (cardiac surgery intensive care unit), DKA (diabetic ketoacidosis), NSTEMI (non–ST segment elevation myocardial infarction), PO (oral), POD (postoperative day), PONV (postoperative nausea/vomiting), SC (subcutaneous), SGLT2i (sodium-glucose cotransporter-2 inhibitors), STEMI (ST segment elevation myocardial infarction), T2DM (type 2 diabetes mellitus)
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