Postoperative outcomes among sodium-glucose cotransporter 2 inhibitor users
Open accessAbstract
Importance: Case reports and small retrospective studies have suggested that there is an increased risk of postoperative euglycemic ketoacidosis (eKA) and acute kidney injury (AKI) among patients using sodium-glucose cotransporter 2 inhibitors (SGLT2i) preoperatively. However, there has not been a representative assessment of the risks of these agents among patients undergoing surgery. Objective: To evaluate the risk of postoperative eKA, AKI, and mortality within 30 days after surgery among preoperative long-term SGLT2i users compared with nonusers. Design, Settings, and Participants: This is a multicenter, propensity-matched, retrospective case-control study from the Veterans Affairs Health Care System (VAHCS) National Registry performed from January 1, 2014, to December 31, 2022. Adult patients using SGLT2i preoperatively who underwent inpatient surgical procedures were compared with a 1:5 matched control group using propensity score matching, including the patient’s demographic characteristics, comorbidities, and surgical characteristics. Data analysis was performed from June 2023 to August 2024. Exposure: Long-term use of SGLT2i, defined as having more than 3 fills of outpatient prescription or less than a 180-day gap of the last fill according to the VAHCS pharmacy registries. Main Outcomes and Measures: The primary outcome was the rate of postoperative eKA among SGLT2i users vs control patients. Secondary outcomes included postoperative AKI and 30-day mortality after surgery. Results: Among 462 968 patients undergoing surgery, 7448 SGLT2i users (mean [SD] age, 67.7 [8.1] years; 7204 [96.7%] male) and 455 520 nonusers (mean [SD] age, 65.8 [11.0] years; 424 785 [93.3%] male) were identified. After propensity score matching, 7439 patients were identified as SGLT2i users and compared with 33 489 control patients. SGLT2i use was associated with an increased risk of eKA (odds ratio [OR], 1.11; 95% CI, 1.05-1.17) but reduced risks of perioperative AKI (OR, 0.69; 95% CI, 0.62-0.78) and 30-day mortality (OR, 0.70; 95% CI, 0.55-0.88). The mortality rate 30 days after surgery was 1.1% among SGLT2i users vs 1.6% among control patients. The median hospital length of stay among the patients presenting with eKA increased by 3 days (median [IQR], 6 [3-10] days for those with eKA vs 3 [2-6] days for those without eKA). Conclusions and Relevance: Patients treated with SGLT2i had a small but significantly higher risk of postoperative eKA but lower risks of postoperative AKI and 30-day mortality.
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Other studies have shown a higher risk of DKA or anion gap acidosis associated with SGLT2 inhibitor use in the perioperative period.
“Other studies have shown a higher risk of DKA or anion gap acidosis associated with SGLT2 inhibitor use in the perioperative period (151-153).”
From 16. Diabetes Care in the Hospital: Standards of Care in Diabetes—2026 (2026) · cites this paper as [151]
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- Authors
- Tallarico, R. T., Jing, B., Lu, K., Chawla, S. A., Luo, Y., Badathala, A., Chen, C. L., Wallace, A. W., & Legrand, M.
- Affiliations
- University of California, San Francisco (US)
- Northern California Institute for Research and Education (US)
- San Francisco VA Medical Center (US)
- Corresponding author
- Legrand, Matthieu
- ORCID
- Venue
- JAMA Surgery
- Publisher
- American Medical Association (AMA)
- Published
- 2025-06-01
- Volume
- 160
- Issue
- 6
- Pages
- 681
- ISSN
- 2168-6254 (ISSN-L)
- PMC
- PMC12044541
- OpenAlex
- W4409962380
- Cited by
- 40
- References
- 44
- Citations by year
- 2026: 28 · 2025: 12
- FWCI
- 27.28
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- cc-by
- Locations
- JAMA Surgery (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Funders
- National Institutes of Health (1r01dk139484-01, R01-GM151494-01)
- University of California, San Francisco (P30 AG044281)
- National Institute on Aging (P30AG044281)
- National Institute of General Medical Sciences (R01-GM151494-01, T32GM008440)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac, Anesthesia and Surgical Outcomes
- Health Sciences › Medicine › Nephrology › Acute Kidney Injury Research
- Keywords
- SGLT2 inhibitors, euglycemic diabetic ketoacidosis, acute kidney injury, postoperative mortality, perioperative risk, surgical patients, preoperative medication use, veterans
- MeSH terms
- Sodium-Glucose Transporter 2 Inhibitors, Aged, Diabetes Mellitus, Type 2, Female, Humans, Male, Middle Aged, Postoperative Complications, Registries, Retrospective Studies, Surgical Procedures, Operative, United States, Case-Control Studies, Propensity Score, Acute Kidney Injury
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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