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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