Patients With Diabetes on Sodium-Glucose Cotransporter-2 Inhibitors Undergoing Total Knee Arthroplasty Are at Increased Odds for a Number of Postoperative Adverse Events But Reduced Risk of Transfusion

Introduction: Diabetes mellitus (DM) is a common comorbidity in total knee arthroplasty (TKA) patients, which has been associated with multiple complications. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are one class of medications recently approved to better manage DM. This study investigates the correlation of SGLT2i use on postoperative complications and revision rates for diabetic patients undergoing TKA. Methods: The M157 PearlDiver database was used to identify DM patients undergoing primary TKA. Those prescribed SGLT2i were identified and matched in 1:4 ratio with control DM patients based on age, sex, obesity diagnosis, and Elixhauser comorbidity index. Ninety-day adverse events and 5-year rates of revision were abstracted and compared by multivariable regression, controlling for age, sex, Elixhauser comorbidity index, long-term insulin use, obesity, metformin use, and active tobacco use. Results: A total of 164,474 TKA patients with DM were identified, of which SGLT2i were prescribed for 9,246 (5.6%). On multivariable analysis, SGLT2i use in DM patients was independently associated with higher odds of aggregated adverse events driven by myocardial infarction (odds ratio [OR] 2.40), sepsis (OR 1.81), urinary tract infection (OR 2.10), pneumonia (OR 1.87), and acute kidney injury (OR 1.33) but had lower odds of transfusion (OR 0.31) ( P < 0.0001 for each). On multivariable analysis, 5-year survival to revision TKA were not markedly different between the matched cohorts. Discussion: SGLT2i are being increasingly prescribed for DM patients undergoing TKA. Although they are associated with increased risk of multiple 90-day perioperative adverse outcomes, they are also associated with reduced incidence of blood transfusion. These results may guide surgical decision making and counseling for patients taking this group of medications and align with some prior studies related to glucagon-like protein-1 agonists.