Farxiga Before Surgery: What the Label Says About the Hold

What the Farxiga label actually says about holding before surgery

Section 2.4 of the Farxiga prescribing information, effective 2026-06-03, is titled "Temporary Interruption for Surgery" [1]. It says to withhold Farxiga for at least 3 days, if possible, prior to surgery or procedures associated with prolonged fasting, and to resume the drug when the patient is clinically stable and has resumed oral intake [1]. The instruction sits in the general Dosage and Administration section rather than under one indication [1].

The phrase "if possible" acknowledges that a planned hold cannot always happen [1]. The label gives a minimum duration of 3 days and does not scale the hold to how major the operation is [1].

Why surgery matters for someone on dapagliflozin

Dapagliflozin blocks SGLT2 in the kidney so that more glucose leaves the body in urine, and that urinary glucose excretion persists for about 3 days after the drug is stopped [1]. The drug also causes an osmotic diuresis [1].

The label's ketoacidosis warning lists surgery as one of the precipitating conditions for diabetic ketoacidosis or other ketoacidosis, alongside reduced caloric intake, a ketogenic diet, volume depletion, acute febrile illness, alcohol abuse, and under-insulinization from reduced or missed insulin doses [1]. It states that blood glucose at presentation may be below 250 mg/dL, lower than typically expected for diabetic ketoacidosis [1]. After an SGLT2 inhibitor is stopped, postmarketing reports describe ketoacidosis and/or glucosuria lasting more than 6 days, and in some cases up to 2 weeks [1].

A clinical review of SGLT2 inhibitor-associated ketoacidosis notes that patients may be euglycemic, with plasma glucose below 14 mmol/L, and lists surgery among the precipitants [2].

Ketoacidosis assessment in the label

The label's warning says to assess for ketoacidosis regardless of presenting blood glucose level in patients with signs and symptoms consistent with severe metabolic acidosis, and to consider ketone monitoring in patients at risk for ketoacidosis if indicated by the clinical situation [1]. It also says to withhold Farxiga, if possible, in temporary clinical situations that could predispose patients to ketoacidosis [1].

Warning signs to know during the hold

The label lists nausea, vomiting, abdominal pain, generalized malaise and shortness of breath as the signs and symptoms of ketoacidosis, consistent with dehydration and severe metabolic acidosis [1]. It says patients should be instructed to discontinue Farxiga and seek medical attention immediately if these occur [1]. If ketoacidosis is suspected, the label says to discontinue the drug, promptly evaluate and treat it, and monitor for resolution before restarting [1].

Restarting Farxiga after surgery

The label has one rule with two conditions: resume when the patient is clinically stable and has resumed oral intake [1]. Section 2.4 gives no postoperative day count and no creatinine or eGFR threshold for restarting [1]. Where ketoacidosis was suspected, the label adds a separate step: monitor for resolution of ketoacidosis before restarting Farxiga [1].

Does the hold apply if Farxiga is for heart failure or kidney disease?

Yes. Section 2.4 of the Farxiga label is not written for one indication [1]. The dose differs by indication: 10 mg once daily for heart failure and chronic kidney disease, and 5 mg once daily (raisable to 10 mg) for glycemic control [1].

Label risk factors that bear on the hold

• Type 1 diabetes. The label says Farxiga significantly increases the risk of diabetic ketoacidosis in type 1 diabetes beyond the background rate, and the drug is not recommended for glycemic control in type 1 diabetes [1].
• Other listed precipitants. A ketogenic diet, reduced caloric intake, volume depletion, acute febrile illness, alcohol abuse and missed or reduced insulin doses all appear in the same warning [1].
• Volume depletion. Patients with an eGFR below 60, older adults, and people taking loop diuretics may be at increased risk of volume depletion or low blood pressure while taking Farxiga [1]. The label asks for volume status and kidney function to be assessed before starting it [1].
• Insulin and sulfonylurea users. The label says a lower dose of insulin or the insulin secretagogue may be required when either is used with Farxiga, to reduce hypoglycemia risk [1].
• Reduced kidney function. Farxiga is not recommended for glycemic control when eGFR is below 45, while the 10 mg heart and kidney indications can be started down to an eGFR of 25 and continued if eGFR later falls below 25 [1].