Farxiga (dapagliflozin) is a medication belonging to the class of sodium-glucose cotransporter-2 (SGLT2) inhibitors. This class of drug has proven beneficial for managing Type 2 Diabetes, Chronic Kidney Disease, and Heart Failure. Its mechanism of action requires temporary interruption when a patient is scheduled for surgery or any procedure involving fasting. The metabolic stress and fluid changes associated with the perioperative period can interact dangerously with the drug. Because of these specific risks, patients must receive individualized medical guidance from their prescribing physician before the planned procedure.
The Specific Risks of SGLT2 Inhibitors During Surgery
The primary concern with continuing dapagliflozin during the perioperative period is the risk of developing euglycemic diabetic ketoacidosis (eDKA). Euglycemic means the blood glucose level is normal or only slightly elevated, which can make DKA difficult to diagnose rapidly. This complication is triggered by the drug’s mechanism and compounded by surgical stress.
Dapagliflozin works by blocking the SGLT2 protein in the kidneys, causing glucose to be excreted in the urine. This loss of glucose signals energy starvation, increasing glucagon production and dropping insulin secretion. The body then breaks down fat for energy through lipolysis, producing an excess of ketones.
Surgical procedures, fasting, and acute illness act as metabolic stressors that accelerate this ketone production. When the body is primed for ketosis by the SGLT2 inhibitor, the lack of carbohydrate intake and stress hormones can quickly lead to a dangerous buildup of acid in the blood.
A secondary risk is acute volume depletion or dehydration. Dapagliflozin causes osmotic diuresis because the glucose being excreted takes water with it. Surgical preparation, which often includes bowel cleanses or periods of being nil per os (NPO), compounds fluid loss. Continuing the drug during this time can lead to low blood pressure, poor kidney perfusion, and acute kidney injury.
Pre-Operative Protocol: Stopping Farxiga
The standard recommendation is to discontinue dapagliflozin for a specific period before the scheduled procedure. The Food and Drug Administration (FDA) advises withholding Farxiga for at least three days prior to major surgery or any procedure associated with prolonged fasting. This timeline allows the medication to clear the patient’s system and reduce the concentration of the drug to minimize the risk of eDKA.
For some procedures that involve a longer-acting SGLT2 inhibitor, a four-day hold may be recommended. Patients must confirm the exact cessation date with the physician who prescribed the medication.
Stopping the medication will result in a temporary loss of blood glucose control. During the three-day gap, the prescribing physician will provide an alternative glucose management plan, which may involve temporary use of short-acting insulin or other oral medications.
Open communication is essential across the entire care team. The patient should inform the surgeon, the anesthesiologist, and their primary care provider that they are taking Farxiga and have followed the protocol to stop it. This coordinated effort ensures all personnel are aware of the potential for eDKA and dehydration during the surgical window and recovery period.
Post-Operative Resumption and Monitoring
The decision to resume Farxiga after a procedure is based on the patient’s clinical status. The drug should only be restarted once the patient has fully recovered from the immediate stress of the surgery and their body’s fluid balance is stable. The patient must be consistently eating and drinking normally to ensure adequate caloric intake and hydration.
For many patients, this stability is achieved approximately 48 hours post-procedure, but the timeline can vary widely depending on the type and severity of the surgery. The treating physician must explicitly approve the resumption of the medication. Before restarting, the care team will verify that the patient is not showing any early signs of complications and that their kidney function remains stable.
Close monitoring for symptoms of eDKA must continue after the procedure, as this complication can manifest several days into recovery. Patients should be vigilant for symptoms such as unexplained nausea, vomiting, abdominal pain, and excessive thirst. Even if blood glucose levels appear normal, these symptoms warrant immediate medical attention and a check for blood ketones.
Monitoring for dehydration is also required, especially if the patient experiences a difficult recovery with poor fluid intake or persistent vomiting. The overarching principle is to wait until the patient is metabolically sound and their ability to stay hydrated is fully restored.