2026 Eastern States Conference

Title: Optimizing Peri-Operative Management of SGLT-2 Inhibitors
Authors: Michele Mathew, PharmD; Jennifer Premus, PharmD; Elaena Quattrocchi, BS, PharmD, FASHP, CDC; Preethi Samuel, PharmD, BCACP, AAHIVP 
Self Assessment Question:
Which of the following best describes the recommended peri-operative management of SGLT-2i to reduce the risk of EDKA?
A. Continue therapy until the morning of surgery
B. Hold the medication 24 hours before surgery
C. Hold the medication at least 72 hours prior to surgery or procedures requiring anesthesia
D. Discontinue therapy only after surgery is completed
Learning Objectives:  
At the conclusion of this presentation, participants will be able to: 
Explain how SGLT-2i contribute to EDKA development in surgical patients
Describe the mechanism of EDKA associated with SGLT-2i use in the peri-operative setting
Evaluate the adherence to institutional SGLT-2i management guidelines
 
Background/Objective: SGLT-2i improve cardiovascular and renal outcomes but their use has been linked to an increased risk of EDKA. Generally, SGLT-2i are held for at least 72 hours prior to surgery or procedure. Currently, there are limited studies evaluating SGLT-2i use in the preoperative setting. By addressing this gap in the literature, the study aims to clarify whether adherence to institutional policies can reduce the rate of EDKA and improve preoperative safety for patients taking SGLT-2i. 
 
Methods: This is a single-center retrospective chart review evaluating adherence to institutional preoperative SGLT-2i protocols and the incidence of EDKA in surgical patients at Staten Island University Hospital. Subjects for inclusion were identified from the electronic medical record as adult patients >18 years who had a procedure or surgery requiring anesthesia between February 22, 2024 - October 1, 2025. Eligible patients must have been prescribed a SGLT-2i prior to surgery or procedure. Exclusion criteria include patients <18 years and pregnancy. The primary outcome will be the percentage of patient's adherent to SGLT-2i institutional preoperative management guidelines. Secondary outcomes will include incidence of EDKA in adherent versus non-adherent patients, patient or surgery-related risk factors associated with EDKA, and clinical outcomes such as hospital length of stay and in-hospital mortality.

Results: Among 517 patients evaluated, only 212 patients (41%) appropriately adhered to Northwell Health’s peri-operative SGLT-2 inhibitor management policy. Policy non-adherence occurred in 305 patients (59%), with the primary reason being unknown SGLT-2 inhibitor hold duration in 288 patients (94.4%), followed by inappropriate medication hold in 17 patients (5.6%). Missing EDKA diagnostic laboratory values were present in 266 patients (87.2%). Mean SGLT-2 inhibitor hold duration was 4.12 ± 1.4 days. No confirmed cases of EDKA were identified in either the appropriately held or non-adherent groups, median hospital length of stay was 2 days (IQR 1–5), and mortality was low at 0.2% (1 patient).

Conclusion: The primary barriers to compliance were largely related to documentation deficiencies, incomplete medication reconciliation, and unclear preoperative hold durations rather than deliberate inappropriate prescribing. Although no confirmed cases of EDKA were identified, the high frequency of missing diagnostic laboratory values likely limited accurate event detection and may underestimate complete incidence. These findings suggest that while institutional guidelines provide an important for reducing perioperative EDKA risk, policy implementation alone is insufficient without effective interdisciplinary education and consistent provider awareness,

Authors: Simran Kaur, PharmD; Jeffrey Hare, PharmD; Brianna Schafer, PharmD, BCPPS; Sewit Araia, PharmD 
Objective: At the conclusion of this presentation, the participant will be able to describe the incidence of severe adverse effects associated with intravenous iron dextran compared with iron sucrose in pregnancy
Pre-assessment question: Which IV iron formulation is associated with a higher risk of severe AE in pregnancy? (A. Iron sucrose B. Iron dextran C. Both have similar risk D. Not sure) 
Background: Intravenous iron is used when oral therapy is inadequate; however, comparative safety data among formulations are limited. This study compares the incidence of severe adverse effects between iron dextran and iron sucrose in pregnant women. 
Methods: This retrospective cohort study included pregnant women of any gestational age who received intravenous iron dextran or iron sucrose within the Geisinger Health System during the iron sucrose shortage from March 25, 2024, to February 20, 2025. Patients were identified using electronic health record medication and diagnosis codes. The primary outcome was the incidence of severe adverse effects, including anaphylaxis, circulatory failure, shock, etc. occurring within 24 hours of iron administration. Secondary outcomes included pre-treatment medications, emergency department admission, hospital admission, and administration of rescue medications. Adverse effects were categorized using Common Terminology Criteria for Adverse Events grading. Primary and secondary outcome incidence rates were compared using fisher’s exact test. 
Results: Data from 150 patients per group were analyzed. Median age was 27 years, with gestational age 33 weeks (iron dextran) and 32 weeks (iron sucrose). Inpatient administration was less frequent with iron dextran (1.33%) vs iron sucrose (9.33%). Adverse events occurred in 2.7% of iron dextran patients and 0% with iron sucrose (p=0.1225). In the dextran group, 38% received premedication, with one ED visit (p=1), no hospitalizations, and 4 patients requiring rescue medications (p=0.1225).
Conclusion: In conclusion, Iron sucrose had zero incidence of adverse events, and they were more often observed in the patients that received iron dextran, however severe adverse events were uncommon. Iron dextran can be considered a safe alternative treatment for iron deficiency anemia in pregnancy when iron sucrose is not readily available as the preferred agent

LEARNING OBJECTIVE: 

1. Learners will be able to recognize opportunities to improve antibiotic prescribing for SSTIs in a community hospital emergency department

BACKGROUND/OBJECTIVE:  This study aims to characterize and evaluate the appropriateness of antibiotic prescribing for skin and soft tissue infections (SSTI) in patients who are discharged from either Cambridge Health Alliance emergency departments (ED).

METHODS: A retrospective chart review will evaluate adult patients (≥18 years of age) discharged from our institution’s emergency departments with a primary chief complaint of cellulitis or abscess. Exclusion criteria include inpatient admission, concomitant or deep tissue infections, bone and joint infections, infections of the mouth, head, neck, or foot, those involving a bite, surgical site, or underlying hardware, or re-presenting within 72 hours of the index admission for the same infection. Treatment data collected includes incision and drainage and antibiotic agent, dose, and duration. Patients will be categorized by wound purulence and IDSA-defined infection severity (mild, moderate, severe). The primary outcome will be adherence of antibiotic agent, dose, and duration prescribing to 2014 IDSA guidelines. Secondary outcomes include readmission within 30 days of the index ED encounter and documented adverse reaction to antimicrobial therapy. 

RESULTS: 200 patients were included in the analysis. Appropriateness was defined as being in compliance with IDSA 2014 guidelines in respect to antibiotic agent, dose, and duration. 32.1% of purulent and 18.8% of nonpurulent infections were prescribed antibiotic regimens in compliance with guideline recommendations. Of these, 56.5% and 71.9% of purulent and nonpurulent infection antibiotics, respectively, were deemed inappropriate due to the duration of therapy. Antibiotic therapy was inappropriate due to broadened coverage in 26.2% and 56.3% of purulent and nonpurulent infections, respectively. In 3.5% and 6.3% of antibiotic regimens, the prescribed dose was below recommended ranges. All cause 30-day readmission was 16.1% and 25% with two documented adverse reactions.

CONCLUSION: It is anticipated that this quality improvement project will provide insight into prescribing practices for SSTIs at our institution’s EDs and opportunities for improvement. Based on these results, the authors plan to propose interventions to the ED which may include additional clinical decision-making support and/or providing departmental education.

SELF ASSESSMENT QUESTION: Which of the following findings is the most appropriate target for an antimicrobial stewardship intervention in adult patients discharged from the ED with SSTIs at our institution?