# SGLT2 inhibitors (perioperative)

> SGLT2 inhibitors such as empagliflozin and dapagliflozin must be withheld before surgery because they can cause euglycaemic diabetic ketoacidosis, in which ketoacidosis develops with normal or near-normal blood glucose. Because withholding must begin days before the procedure, the plan has to be made at booking rather than on admission.

*Source: https://getpathways.ai/glossary/sglt2-inhibitor-perioperative*

Also known as: gliflozins, empagliflozin, dapagliflozin, SGLT2i

- **Drug class**: Sodium-glucose co-transporter 2 inhibitors
- **Common agents**: Empagliflozin, dapagliflozin, ertugliflozin
- **Perioperative risk**: Euglycaemic diabetic ketoacidosis (eDKA)
- **Why it is missed**: Blood glucose can be normal, so the usual signal is absent
- **Guidance**: ANZCA and Australian Diabetes Society perioperative guidance

## Why the risk is unusual

Diabetic ketoacidosis is normally accompanied by a high blood glucose, which is
what prompts the diagnosis. SGLT2 inhibitors can produce ketoacidosis with a
glucose that is normal or only mildly raised — euglycaemic DKA. The safety
problem is therefore diagnostic as much as pharmacological: the signal
clinicians are trained to look for is absent, so the condition is recognised
late.

Surgery adds precisely the stressors that precipitate it: fasting, dehydration,
and the physiological stress response.

## Why it becomes a cancellation

Withholding has to start days before the operation. That makes it a booking-time
decision, not an admission-time one. A patient who arrives on the morning of
surgery still taking their gliflozin cannot be made safe by any decision
available that morning, so the case is cancelled.

The failure is almost never clinical judgement. It is that nobody knew the
patient was on the drug. Patients routinely describe it as "a tablet for sugar",
and a GP summary eight months old may predate the prescription.

## How Pathways catches it

During the voice interview, patients photograph their medication boxes. Each
image is read — handwriting included — classified, and the extracted values
verified against the source image before entering the record. An identified
SGLT2 inhibitor with no documented withholding plan for the surgery date raises
a critical-tier flag citing the ANZCA and ADS guidance, with the rule version
and the evidence that triggered it attached.