Sodium‐glucose co‐transporter type‐2 inhibitors: is the message getting through?

Last year, Milder et al. brought the emerging problem of peri-operative euglycaemic ketoacidosis associated with sodium-glucose cotransporter type-2 inhibitors (SGLT2s) to our attention 1. Having seen the devastating consequences of this complication in cardiac surgical patients, we recently changed our local guidelines for such patients and plan to do the same for all types of major surgery across the hospital. The key message is that SGLT2s should be withheld for at least 3 days before major surgery (and longer for those receiving a ketotic diet). When this is not possible, such as in the context of urgent or emergency surgery, blood ketones should be regularly monitored. We were pleased to see SGLT2s mentioned in recent articles on pre-operative optimisation of the surgical patient with diabetes 2 and a review of best practice for patients undergoing emergency laparotomy 3. That said, it is our impression that many clinicians remain unaware of the potential for peri-operative euglycaemic ketoacidosis in such patients, the clinical consequences and how the diagnosis may be delayed or discounted. It is perhaps unfortunate that the peri-operative hazards of SGLT2s emerged so soon following the 2015 Association of Anaesthetists guideline on the management of the surgical patient with diabetes 4. The authors of this guideline advise that SGLT2s should be continued until the morning of surgery, when half the usual dose should be taken. Given the majority of hospitals in the UK use such guidelines to inform local policy, and that reports of SGLT2-associated euglycaemic ketoacidosis in the peri-operative period continue to emerge 5, is it time to consider an expedited update?