Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast Episode 329: SGLT2 inhibitors and GLP1 Receptor Agonists with Dr. Tyler Jones
Mar 7, 2026
Dr. Tyler Jones, a board-certified anesthesia provider and founder of the Anesthesia Thoughts blog who recently added obesity medicine certification, joins to discuss SGLT2 inhibitors and GLP-1 receptor agonists. He covers mechanisms and perioperative risks like euglycemic DKA and delayed gastric emptying. Practical approaches include ketone testing, tailored hold policies, gastric ultrasound, and fasting strategies.
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SGLT2 Mechanism Raises Ketosis Risk
- SGLT2 inhibitors lower insulin and raise glucagon, which promotes ketogenesis and increases baseline risk of ketoacidosis.
- Risk amplifies with stressors like infection, fasting, or surgery because reduced insulin removes inhibition of ketone production.
Perioperative DKA Evidence Is Limited
- Retrospective emergency-surgery data did not show a significant increase in perioperative DKA for patients on SGLT2 inhibitors.
- Studies are limited by design, ICD-10 coding gaps for euglycemic DKA, and inability to prove causation without RCTs.
Measure Ketones Instead Of Automatic Cancellation
- If a patient on an SGLT2 inhibitor forgot to hold the med, check serum beta-hydroxybutyrate preoperatively to assess ketone risk.
- Use cutoffs ~1.5–2.0 mmol/L for concern and ≥3 mmol/L as higher ketoacidosis risk; <0.5 mmol/L implies low risk.
