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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