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Oosterom-Eijmael MJP, Hermanides J, van Raalte DH, Hulst AH. Risk of perioperative discontinuation of SGLT2 inhibitors. Br J Anaesth 2024:S0007-0912(24)00272-1. [PMID: 38834489 DOI: 10.1016/j.bja.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 05/01/2024] [Accepted: 05/03/2024] [Indexed: 06/06/2024] Open
Abstract
When sodium-glucose cotransporter-2 (SGLT2) inhibitors were primarily prescribed for treatment of diabetes mellitus, guidelines recommended withholding SGLT2 inhibitors before surgery to mitigate the associated risk of ketoacidosis. However, currently, SGLT2 inhibitors are an established therapy for patients with heart failure, and there is evidence that withholding SGLT2 inhibitors can worsen these patients' cardiovascular risk profile. We present an updated risk-benefit analysis of withholding SGLT2 inhibitors before surgery, focusing on patients with heart failure and addressing the risk of ketoacidosis and its treatment in these patients. Clinicians should consider perioperative continuation of SGLT2 inhibitors when prescribed for treatment of heart failure.
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Affiliation(s)
- Maartina J P Oosterom-Eijmael
- Department of Anaesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands; Department of Endocrinology and Metabolism, Amsterdam University Medical Center, Amsterdam, The Netherlands; Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands
| | - Jeroen Hermanides
- Department of Anaesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
| | - Daniel H van Raalte
- Department of Endocrinology and Metabolism, Amsterdam University Medical Center, Amsterdam, The Netherlands; Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands
| | - Abraham H Hulst
- Department of Anaesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
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Gao WD. One size does not fit all: Perioperative management of patients with heart failure with preserved ejection fraction. J Clin Anesth 2024; 94:111409. [PMID: 38340679 DOI: 10.1016/j.jclinane.2024.111409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 12/18/2023] [Accepted: 02/03/2024] [Indexed: 02/12/2024]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is recognized as an important risk factor for perioperative complications. However, anesthesia management of HFpEF patients remains a considerable challenge without clear guidance. HFpEF is heterogeneous in its pathophysiological processes, diverse clinical presentations, adverse remodeling of cardiovascular and other organs, and clinical outcomes. It is difficult to manage the disease with one fixed approach because of this. This review phenotypes HFpEF patients by combining their clinical features and anesthesia care issues. Five phenotypes of HFpEF patients are identified: A, O, P, C, and Y. The clinical features, anesthesia implications, and anesthesia management for each phenotype are highlighted and discussed. Such an approach to HFpEF patients in the operating room could deliver safe, high-quality perioperative care.
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Steinhorn B. Dose-dependent relationship between SGLT2 inhibitor hold time and risk for postoperative anion gap acidosis. Response to Br J Anaesth 2023; 131: 682-686. Br J Anaesth 2024; 132: 822-3. Br J Anaesth 2024; 132:993-994. [PMID: 38448270 DOI: 10.1016/j.bja.2024.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 01/31/2024] [Indexed: 03/08/2024] Open
Affiliation(s)
- Benjamin Steinhorn
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.
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Heijne A, Bronkhorst EM. Dose-dependent relationship between SGLT2 inhibitor hold time and risk for postoperative anion gap acidosis. Comment on Br J Anaesth 2023; 131: 682-686. Br J Anaesth 2024; 132:822-823. [PMID: 38320879 DOI: 10.1016/j.bja.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/12/2024] [Indexed: 02/08/2024] Open
Affiliation(s)
- Amon Heijne
- Department of Anaesthesiology, Pain and Palliative Care, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Ewald M Bronkhorst
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
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Dhatariya K, Levy N, Russon K, Patel A, Frank C, Mustafa O, Newland-Jones P, Rayman G, Tinsley S, Dhesi J. Perioperative use of glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter 2 inhibitors for diabetes mellitus. Br J Anaesth 2024; 132:639-643. [PMID: 38290906 DOI: 10.1016/j.bja.2023.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/08/2023] [Accepted: 12/21/2023] [Indexed: 02/01/2024] Open
Abstract
Type 2 diabetes mellitus is an increasingly common long-term condition, and suboptimal perioperative glycaemic control can lead to postoperative harms. The advent of new antidiabetic drugs, in particular glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose cotransporter 2 (SGLT2) inhibitors, has enabled perioperative continuation of these medicines, thus avoiding the harms of variable rate i.v. insulin infusions whilst providing glycaemic control. There are differences between medicines regulatory agencies and organisations on how these classes that are most often used to treat diabetes mellitus, (but also in the case of SGLT2 inhibitors chronic kidney disease and heart failure in those without diabetes) should be managed in the perioperative period. In this commentary, we argue that GLP-1 receptor agonists should continue during the perioperative period and that SGLT2 inhibitors should only be omitted the day prior to a planned procedure . The reasons for the differing advice advocated between regulatory agencies and what anaesthetic practitioners should do in the face of continuing uncertainty are discussed.
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Affiliation(s)
- Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, UK; Norwich Medical School, University of East Anglia, Norwich, UK.
| | - Nicholas Levy
- Department of Anaesthetics, West Suffolk Hospital, Bury St Edmonds, Suffolk, UK
| | - Kim Russon
- Department of Anaesthetics, The Rotherham NHS Foundation Trust Hospital, Rotherham, UK
| | - Anil Patel
- Department of Anaesthetics, The Royal National ENT & Eastman Dental Hospitals, University College London Hospitals, London, UK
| | - Claire Frank
- Pharmacy Department, Betsi Cadwaladr University Health Board, Wrexham, UK
| | - Omar Mustafa
- Department of Diabetes, King's College Hospital, London, UK; King's College, London, UK
| | - Philip Newland-Jones
- Department of Diabetes & Endocrinology, Southampton General Hospital, Southampton, UK
| | - Gerry Rayman
- Ipswich Diabetes Centre, East Suffolk and North Essex NHS Foundation Trust, Ipswich, UK
| | - Sarah Tinsley
- Pharmacy, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Jugdeep Dhesi
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
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6
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Ryz S, Castellucci C. Should Patients Taking Sodium-Glucose Co-Transporter 2 Inhibitors Be Dropped From the Elective Surgical Program? J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00108-3. [PMID: 38622033 DOI: 10.1053/j.jvca.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 02/12/2024] [Indexed: 04/17/2024]
Affiliation(s)
- Sylvia Ryz
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria.
| | - Clara Castellucci
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
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Ruste M, Schweizer R, Groisne L, Fellahi JL, Jacquet-Lagrèze M. Sodium-glucose cotransporter-2 inhibitors in non-diabetic patients: is there a perioperative risk of euglycaemic ketoacidosis. Br J Anaesth 2024; 132:435-436. [PMID: 38052677 DOI: 10.1016/j.bja.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 11/07/2023] [Accepted: 11/13/2023] [Indexed: 12/07/2023] Open
Affiliation(s)
- Martin Ruste
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron, France; Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France; Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, Lyon, France.
| | - Rémi Schweizer
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron, France
| | - Laure Groisne
- Fédération d'Endocrinologie, de Diabétologie et des Maladies Métaboliques, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron, France
| | - Jean-Luc Fellahi
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron, France; Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France; Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, Lyon, France
| | - Matthias Jacquet-Lagrèze
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron, France; Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France; Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, Lyon, France
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