SGLT2 Inhibitors: Perioperative Management and Euglycemic Ketoacidosis

SGLT2 抑制劑因其心腎保護效益在接受手術的第二型糖尿病病人中日益常見，但藥物機轉會提升酮體生成並降低血糖，使「無高血糖酮酸中毒」成為重要圍手術風險。最新美國糖尿病學會 2025 標準及多數專家共識建議，選擇性停藥三天（72 小時）可明顯降低術後 eDKA 發生率，若預期術式大、禁食時間長或病人伴隨腎功能不全，應延長至四天。機轉上，SGLT2 抑制劑透過抑制腎近曲小管回收葡萄糖，術中禁食與壓力賀爾蒙進一步促進脂肪酸氧化與酮體累積；胰島素分泌相對不足時，即使血糖低於 250 mg/dL 仍可能出現顯著代謝性酸中毒。臨床觀察研究顯示，手術前三天內仍持續用藥者，術後 30 天內再入院與酸中毒風險增加；相反地，在非緊急手術中確實停藥三至四天並以基礎胰島素或 GLP-1 促效劑替代，既可維持血糖又可避免酸中毒。建議的圍手術管理流程一 停藥前評估：辨識高危病人如低碳水飲食、感染、慢性腎病與心衰。二 停藥時機：選擇性手術前 72 至 96 小時暫停；緊急手術則立即停藥並加強監測。三 術前控制：使用基礎胰島素搭配靜脈葡萄糖，維持血糖 90–180 mg/dL，並每 6 小時測動脈血氣與β-羥丁酸。四 術後監測：至少 48–72 小時持續監控酸鹼狀態，待口服進食穩定、腎功能無惡化且酮體陰轉後再恢復 SGLT2 抑制劑。透過系統化停藥、替代降糖策略與積極酮體監控，可在維持心腎獲益的同時，最大幅度降低 eDKA 的罕見但致命風險。[1]: https://diabetesjournals.org/care/article/48/Supplement_1/S321/157551/16-Diabetes-Care-in-the-Hospital-Standards-of-Care?utm_source=chatgpt.com "16. Diabetes Care in the Hospital: Standards of Care in Diabetes ..."[2]: https://health.ucdavis.edu/news/headlines/why-sglt2-inhibitors-should-be-stopped-before-surgery/2024/01?utm_source=chatgpt.com "Why SGLT2 inhibitors should be stopped before surgery"[3]: https://www.apsf.org/article/editorial-euglycemic-ketoacidosis-concerns-in-perioperative-use-of-sglt2-inhibitors-re-examining-current-recommendations/?utm_source=chatgpt.com "Editorial: Euglycemic Ketoacidosis Concerns in Perioperative Use of ..."[4]: https://www.apsf.org/wp-content/uploads/newsletters/2025/4001/APSF4001-a05-Euglycemic-Ketoacidosis.pdf?utm_source=chatgpt.com "[PDF] PDF - Anesthesia Patient Safety Foundation"[5]: https://jamanetwork.com/journals/jamasurgery/article-abstract/2830464?utm_source=chatgpt.com "Preoperative SGLT2 Inhibitor Use and Postoperative Diabetic ..."[6]: https://jamanetwork.com/journals/jamasurgery/fullarticle/2833369?utm_source=chatgpt.com "Postoperative Outcomes Among Sodium-Glucose Cotransporter 2 ..."