[Sodium-Glucose Cotransporter-2 (SGLT-2) inhibitors in perioperative medicine : Effects, side effects and current recommendations].

Sodium-glucose Cotransporter 2 (SGLT-2) inhibitors are oral antidiabetic drugs that were developed for the treatment of patients with diabetes mellitus and are now also approved for treating chronic heart failure and chronic kidney disease. By inhibiting SGLT‑2 in the proximal renal tubule, urinary excretion of glucose is increased. Large randomized trials have demonstrated improved glycemic control, reduced cardiovascular events and lower mortality but also an increased risk of urogenital infections and dehydration. Of particular concern is an increasing number of reports describing postoperative (euglycemic) ketoacidosis in patients on treatment with SGLT-2 inhibitors, which is a rare but potentially life-threatening side effect which is difficult to detect. The extremely limited data situation is reflected in the heterogeneous recommendations, surgical stress, prolonged fasting and metabolic changes are considered key triggers. International guidelines recommend withholding SGLT-2 inhibitors 3-4 days before elective surgery, whereas an increase in undesired events has been described when discontinuing the medication in patients with heart failure. This indicates that a one-size-fits-all approach is unsuitable and an individualized, risk-stratified strategy that considers the risk of surgery, fasting duration and ketone monitoring appears to be more appropriate. The lack of evidence for the approach in emergency situations, limited availability of blood ketone testing and unclear guidance on when to restart treatment further complicate perioperative management. This review outlines the effects and side effects of SGLT-2 inhibitors and summarizes the current recommendations for perioperative management.