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Diabetic Medication Perioperative Management

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Perioperative Diabetic Medication Management for Patients Undergoing Elective and Emergency Surgery

Perioperative Diabetic Medication Management for Patients Undergoing Elective and Emergency Surgery1, 2

Oral Hypoglycaemics

SGLT-2: Sodium-Glucose Cotransporter 2, DPP-IV: Dipeptidyl Peptidase IV, GLP-1: Glucagon-Like Peptide 1

*SGLT2is: Diabetic ketoacidosis (inc with normal BGL) has been reported in patients taking SGLT2is.

Risk Factors include conditions leading to a restricted food/ fluid intake, including bowel preparation or prior to bariatric surgery. SGLT2is should be withheld pre-operatively at least on day of surgery and the day prior. Withholding for the 2 days prior to surgery is appropriate in settings of reduced food intake pre-operatively and for major procedures.

Patients admitted for major surgery, surgical emergencies or major illness should have SGLT2is withheld and blood ketones monitored daily.</p?

DO NOT restart until eating and drinking normally, any volume depletion has been corrected, any insulin infusions have been ceased, ketone levels are normal and patient is medically stable. Once restarted, check blood ketones daily while an inpatient.

For patients on SGLT2i who have not appropriately withheld their SGLT2i, refer to the algorhythm below

Advice in this area is evolving rapidly.

The above table is based on UK advice1 from March 2021, with Australian Updates2 from Jan 2022 on SGLT2i Management.

US Guidelines13 (Jan 2021) remain more conservative than UK guidelines, suggesting withholding SGLT2is 3-4 days pre-op and withholding metformin in all cases on DOS.

**Metformin only needs to be withheld if:

  • contrast medium is to be used
  • Or baseline eGFR is < 60ml/1.73m2
  • patient is deemed at significant risk of perioperative decline in renal function

In these cases, metformin should be omitted on the day of the procedure and for the following 48 hours, until renal function is confirmed to be normal. Patients admitted for surgical emergencies or acute illness should have metformin held if GFR < 30ml/min.

Oral Hypoglycaemic Trade Names and Drug Class

Management of Insulin

Download PDF Version of Diabetic Quick Reference Tables HERE

Available Forms of Insulin in Australia

Types of Insulin
Brand name Type
Mealtime or prandial insulins
Ultra rapid-acting

Onset in 5–10 minutes, peak at 30 minutes, duration for 3.5–4 hours
FiAsp Faster insulin aspart
Rapid-acting

Onset in 15–20 minutes, peak at one hour, duration for 3.5–4.5 hours
Humalog Insulin lispro
NovoRapid Insulin aspart
Apidra Insulin glulisine
Short-acting

Onset in ~1 hour, peak at two to five hours, duration for six to eight hours
Actrapid Neutral
Humulin R
Basal insulins
Intermediate-acting
Humulin NPH Isophane
Protaphane
Levemir Insulin detemir

Onset in three to four hours, peak at three to eight hours, duration for 20–24 hours
Optisulin   Insulin glargine (U100)

Onset in one to two hours, flat, duration for 18–24 hours
Semglee
Toujeo Insulin glargine (U300)

Onset in one to two hours, flat, duration for 24–36 hours
Premixed insulins
Humalog Mix 25 Lispro 25%/lispro protamine 75%

Onset in 15–20 minutes, peak at one hour, duration for 14–24 hours
Humalog Mix 50 Lispro 50%/lispro protamine 50%

Onset in 15–20 minutes, peak at one hour, duration for 14–24 hours
NovoMix 30 Insulin aspart 30%/insulin aspart protamine 70%

Onset in 15–20 minutes, peak at one hour, duration for 14–24 hours
Humulin 30/70 Neutral 30%/isophane 70%

Onset in one to two hours, peak at two to five hours, duration for 12–18 hours
Mixtard 30/70
Mixtard 50/50 Neutral 50%/isophane 50%

Onset in one to two hours, peak at two to five hours, duration for 12–18 hours
Ryzodeg 70/30 Insulin degludec 70% and insulin aspart 30%

Onset in 5–20 minutes, peak at one hour, duration for 36–48 hours

Management of Diabetic Medications for Colonoscopy

Management of Diabetic Medications for Colonoscopy

Day -2 : Day of Low Fibre Meals

Continue all usual diabetic medications EXCEPT SGLT2 INHIBITORS

Day -1 : Day of Fluids Only

Oral Hypoglycaemics

OMIT all diabetic medications except insulin

Insulin

Rapid acting insulin

  • OMIT

Mixed-Insulin

  • 50% usual morning insulin
  • 30-50% usual evening insulin
  • Ryzodeg (insulin Degludec/ insulin Aspart)
    • give 50% dose in the morning if usually a morning dose
    • Consider omitting if usually an evening dose OR give 50% in the morning that day

Glargine

  • continue usual dose (if any) in morning
  • 50% of usual dose in evening at usual time

Protaphane/ Humulin NPH/ Levemir

  • Morning: 50% of usual TOTAL morning (morning + lunch) insulin dose
  • Evening: 50% of usual dose as usual time

Day of Colonoscopy

Ideally should be scheduled first on a morning list (esp if insulin treated)

Oral Hypoglycaemics

  • Withhold morning dose
  • Resume normal diabetic medications for lunch time

Short acting Insulin / Pre-mixed Insulin

  • Withhold Pre-Procedure
  • Have half usual pre-breakfast dose prior to first meal after the procedure

Long Acting Insulin

  • Continue as usual, including morning dose with no dose reduction

Perioperative Management of Patients with inadequately withheld SGLT2 Inhibitors

Perioperative Management of Patients with inadequately withheld SGLT2 Inhibitors3

INDEX TERMS Nateglinide Repaglinide Glibenclamide Gliclazide Glimepiride Glipizide Glyburide Canagliflozin Danagliflozin Empagliflozin Acarbose Alogliptin Linagliptin Saxagliptin Sitagliptin Vildagliptin Exenatide Liraglutide Metformin Pioglitazone Rosiglitazone

Correction of Hyperglycaemia

The following calculations are a guide only and err on the conservative side.

Insulin Sensitivity ≈ 80TDD

In the absence of known TDD,  a rough estimate of TDD can be made from:

TDD ≈ Body Weight (kg) x 12

References

  1. Guideline for Perioperative Care for People with Diabetes Mellitus Undergoing Elective and Emergency Surgery - CPOC - 2021
  2. ADS Periprocedure DKA with SGLT2i - July 2022 Update
  3. ADS Periprocedural DKA with SGLT2i Use in People With Diabetes - ALERT UPDATE Jan 2022
  4. Periprocedural Diabetic Ketoacidosis with SGLT2i Use – ADS Update – September 2020
  5. Perioperative Management of the Surgical Patient with Diabetes – Anaesthesia 2015
  6. Association Between Acute Phase Perioperative Glucose Parameters and Postoperative Outcomes in Diabetic and Non-Diabetic Patients Undergoing Non-Cardiac Surgery – Am J Surg 2019
  7. Diabetic Medication Management for Colonoscopy - PeriOp SIG 2019
  8. Australian Diabetic Society - Perioperative Diabetes Management Guidelines - 2012
  9. AAGBI - Peri‐operative management of the surgical patient with diabetes - Anaesthesia 2015
  10. Management of diabetes and hyperglycaemia in the hospital - Lancet Diabetes Educational 2021
  11. NHS - Peri-Operative Management of Diabetes in Adults - 2018
  12. Perioperative Hyperglycemia Management - An Update - Anesthesiology 2017
  13. Diabetes Care in the Hospital – Standards of Medical Care in Diabetes – Diabetes Care 2021
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