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,