Balancing the evidence with the SPAQI recommendations: from perioperative discontinuation towards continuation of SGLT2 inhibitors.

Abstract

The Society for Perioperative Assessment and Quality Improvement consensus recommends a perioperative management strategy for sodium-glucose cotransporter 2 inhibitors based on surgical type, metabolic context, and underlying indication. This risk-stratified approach balances the low but real risk of euglycaemic ketoacidosis against established cardio-renal benefits. Current evidence is limited and suggests that euglycaemic ketoacidosis is driven more by metabolic context, particularly diabetes mellitus and fasting, than by drug continuation alone. Importantly, discontinuation could lead to a loss of cardiovascular benefit, whereas emerging data suggest potential perioperative benefits, although evidence remains limited. Overall, these recommendations shift toward a strategy based on euglycaemic ketoacidosis risk factors and careful metabolic monitoring rather than systematic discontinuation pending large randomised controlled trials.