SGLT2 inhibitors

 

Drug:

Kinetics

·     Rapid onset

·     Slow offset (half life 12-24 hours)

·     Undergo glucuronidation

·     Contraindicated in severe renal impairment

Dynamics

·     Competitively inhibit SGLT2

·     Reduce glucose reabsorption by 30-50%

·     Glycosuria 50-100g/days

Benefits

·     Diabetes: prevent hyperglycaemia, prevent CKD

·     Heart failure: natriuresis, reduce admissions

·     Hypertension: natriuresis

·     Obesity: weight loss several kg

 

SGLT2-induced DKA:

Risk factors

·     Major stress

·     Not enough carbs

·     Not enough insulin

Causes

·     Concealed insulin insufficiency

·     Direct stimulation of alpha cells

Presentation

Main things:

·     Symptoms: nausea, vomiting, abdominal pain

·     Signs: dehydration, tachycardia, altered mental status

·     Often missed!

BSL:

·     Euglycaemic (BSL <14, usually ~10)

·     Hyperglycaemic, mild acidosis

Differentiation from diet-induced ketosis:

·     Unwell

·     Faster onset

·     Higher ketones (>3)

·     Acidosis uncompensated

Treatment

·     Fluid

·     Insulin

·     Glucose

·     Potassium

 

Peri-op management of drug:

When to cancel

·     Ketones >0.6 (needs more insulin)

·     HbA1c >9% (needs more insulin)

When to cease drug

Note long half life

·     Minor surgery: on the day

·     Major surgery: 2 days before (note disagreements)

·     Bariatric surgery: while on VLCD i.e. 2-4/52

·     Colonoscopy: when diet changes i.e. 2-3 days

·     If on combo drug: stop both if diabetes mild and well controlled

When to restart drug

·     Eating properly

·     Stress subsiding

General tips

·     Communication between anaesthetist, endo and surg

·     Expect hypovolaemia

·     Measure ketones and sugar. Q4h if high risk

·     Insulin and glucose if in doubt

 

 

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