Diabetes - A Summary


For further information on individual agents, please refer to individual monographs

     
     Management of Insulin in the Perioperative period 

When reducing insulin doses round to the nearest unit.   

Figure 1 summarises the perioperative advice for LONG-ACTING insulin.  For further details please consult the individual monograph.

Time and Frequency of AdministrationBrands of InsulinDay before OperationDay of SurgeryIf VRIII being used
Morning OperationAfternoon Operation
ONCE Daily (in the morning)Abasaglar® Humulin I® Insulatard® Insuman® Basal Lantus® Levemir® Semglee® Toujeo® Tresiba® Suliqua®* Xultophy®*Take as usual
Give 80% of usual dose Check capillary blood glucose (CBG) on admission
Continue at 80% of usual dose
ONCE Daily (at lunchtime)Give 80% of usual doseCheck CBG on admission
ONCE Daily (in the evening)Give 80% of usual doseCheck CBG on admission
TWICE Daily Take morning dose as usual but give 80% of usual evening doseGive 80% of usual morning dose
Check CBG on admission

*in combination with Glucagon-Like Peptide-1 (GLP-1) Receptor Agonist.  The doses for both Suliqua and Xultophy are expressed in terms of ‘dose steps’ (where 10 dose steps refers to 10 units of insulin).

Figure 1 – Management of LONG-ACTING insulin in the Perioperative Period

Figure 2 summarises the perioperative advice for PREMIXED insulin. For further details please consult the individual monograph.

RegimenBrands of InsulinDay before OperationDay of SurgeryIf VRIII being used
Morning OperationAfternoon Operation
TWICE DailyHumalog Mix® 25 Humalog Mix® 50 Humulin® M3 Hypurin Porcine® 30/70 mix Insuman Comb® 15 Insuman Comb® 25 Insuman Comb® 50 NovoMix® 30No dose changeHalve usual morning dose

Check capillary blood glucose (CBG) on admission

Resume usual evening insulin if eating a normal meal.  If eating a half / small meal give half usual dose. If not eating give basal only component of the usual mixed insulin*
Stop until eating and drinking and replace with a long-acting insulin at a dose of 0.2 units per kilogram
THREE Times DailyHalve usual morning dose

Check CBG on admission

 Omit lunchtime dose

 Resume evening insulin if eating a normal meal.  If eating a half / small meal give half usual dose. If not eating give basal only component of the usual mixed insulin*

*e.g. Humulin® M3 contains isophane insulin 70units per 1ml and soluble insulin 30units per 1ml therefore give 70% of usual dose as Humulin® I (isophane insulin).  For the insulin analogues the basal component is not available separately as a commercially available product therefore for Novomix® 30 use 70% of usual dose as Insulatard® (isophane insulin) and for Humalog® 25 use 75% of usual dose as Humulin I® (isophane insulin).   

Figure 2 – Management of PREMIXED insulin in the Perioperative Period   

 Figure 3 summarises the perioperative advice for SELF-MIXED insulin.  For further details please consult the individual monograph.

RegimenBrands of InsulinDay before OperationDay of SurgeryIf VRIII being used
Morning OperationAfternoon Operation
TWICE DailyShort-acting Actrapid® Apidra® Fiasp® Humalog®  Humulin® S Hypurin® Porcine Neutral Insuman® Infusat Insuman® Rapid, NovoRapid® Intermediate-acting Humulin® I Hypurin® Porcine Isophane Insulatard® Insuman® BasalNo dose changeCalculate the total dose of both morning insulins and give half of this total dose as intermediate-acting insulin only in the MORNING

Check capillary blood glucose (CBG) on admission

Resume usual evening insulin if eating a normal meal.  If eating a half / small meal give half usual dose.  If not eating only give intermediate-acting component of the usual mixed insulin
Stop until eating and drinking and replace with a long-acting insulin at a dose of 0.2 units per kilogram

Figure 3 – Management of SELF-MIXED insulin in the Perioperative Period 

Figure 4 summarises the perioperative advice for SHORT-ACTING insulin.  For further details please consult the individual monograph.

RegimenBrands of InsulinDay before OperationDay of SurgeryIf VRIII being used
Morning OperationAfternoon Operation
TWO to FOUR injections daily with mealsActrapid® Apidra®  Fiasp® Humalog® Humulin® R Humulin® S Hypurin® Porcine Neutral Insuman® Infusat Insuman® Rapid  Lyumjev  NovoRapid®No dose changeOmit morning dose if no breakfast eaten

Check capillary blood glucose (CBG) on admission

Omit lunchtime dose if not eating and drinking normally

Resume usual evening insulin if eating a normal meal. If eating a half / small meal give half usual dose

If not eating, ensure usual basal component of insulin regimen is still administered
(see Long-acting Insulin monograph)
Take usual morning dose with breakfast

Omit lunchtime dose if not eating

Check CBG on admission

Resume usual evening insulin if eating a normal meal. If eating a half / small meal give half usual dose

If not eating, ensure usual basal component of insulin regimen is still administered
 (see Long-acting Insulin monograph)
Stop until eating and drinking but continue long-acting insulin at 80% of usual dose.  (If not usually prescribed long-acting insulin commence at dose of 0.2 units per kilogram)
  (see Long-acting Insulin  monograph)

Figure 4 – Management of SHORT-ACTING insulin in the Perioperative Period

 

     
     Management of Non-insulin Diabetic Medication in the Perioperative Period

Figure 5 summarises the perioperative advice for non-insulin diabetic medications.  For further details please consult the individual monographs.

Drug Class

ExamplesMorning operationAfternoon operationPost-operative advice
Acarbose-Omit morning dose if nil by mouthTake morning dose if eatingRestart once eating and drinking normally and VRIII (if used) has been stopped
DDP IV inhibitors*Alogliptin Linagliptin Saxagliptin Sitagliptin VildagliptinContinueRestart once eating and drinking normally and VRIII (if used) has been stopped
GLP-1 analoguesAlbiglutide Dulaglutide Exenatide Exenatide MR Liraglutide LixisenatideContinueContinue even if VRIII used
MeglitinidesNateglinide RepaglinideOmit morning dose if nil by mouthTake morning dose if eatingRestart once eating and drinking normally and VRIII (if used) has been stopped
Metformin (including MR)*-Once or twice daily dosing: continue** Three times daily dosing: omit lunchtime dose on day of surgery**Once eating and drinking normally and VRIII (if used) has been stopped, check eGFR and follow advice in Metformin monograph
Pioglitazone*-ContinueRestart once eating and drinking normally and VRIII (if used) has been stopped
SGLT2 inhibitors*Canagliflozin Dapagliflozin Empagliflozin ErtugliflozinOmit dose on day before AND day of operation***Only restart once eating and drinking normally, any volume depletion has been corrected, ketone levels are normal, patient is medically stable and VRIII (if used) has been stopped
SulfonylureasGlibenclamide Gliclazide Gliclazide MR Glimepiride Glipizide TolbutamideOmit morning doseOmit morning and afternoon doseRestart once eating and drinking normally and VRIII (if used) has been stopped.  Patients having afternoon surgery should delay restart until next day.

 * For combination products refer to figure 6 for perioperative medication advice
** If eGFR<60 and contrast media is planned omit metformin on the day of surgery and for 48 hours post-operatively
*** If restricted dietary intake expected see SGLT-2 inhibitor monograph for advice

Figure 5 – Management of non-insulin diabetic medications in the Perioperative Period

Combination Products 
Consideration should be given to prescribing the individual components separately so that the usual perioperative advice can be followed for each component (as per the individual monographs). This is particularly important for combination products containing SGLT-2 inhibitors which require a longer period of treatment interruption.

If this is not possible figure 6 summarises the perioperative advice for medications containing more than one non-insulin diabetic medication.

Combination Product
Examples
Morning operationAfternoon operationPost-operative advice
Metformin+ pioglitazoneCompetact®Continue*Once eating and drinking normally and VRIII (if used) has been stopped, check eGFR and follow advice in Metformin monograph

Metformin+ DPP-IV InhibitorsEucreas® Janumet® Jentadueto® Komboglyze® Vipdomet®Continue*Once eating and drinking normally and VRIII (if used) has been stopped, check eGFR and follow advice in Metformin monograph

Metformin+ SGLT-2 InhibitorsSynjardy® Vokanamet® Xigduo®Omit dose on day before AND day of operation**Only restart once eating and drinking normally, any volume depletion has been corrected, ketone levels are normal, patient is medically stable and VRIII (if used) has been stopped
SGLT-2 Inhibitors + DPP-IV InhibitorsGlyxambi® Qtern®Omit dose on day before AND day of operation**Only restart once eating and drinking normally, any volume depletion has been corrected, ketone levels are normal, patient is medically stable and VRIII (if used) has been stopped

* If eGFR<60 and contrast media is planned omit metformin on the day of surgery and for 48 hours post-operatively 
** If restricted dietary intake expected see SGLT-2 Inhibitor monograph for advice

Figure 6 – Management of combination products containing more than one non-insulin diabetic medication in the Perioperative Period


Reference 
Centre for Perioperative Care. Guideline for Perioperative Care for People with Diabetes Mellitus Undergoing Elective and Emergency Surgery (March 2021). Available at: https://cpoc.org.uk/guidelines-resources/guidelines [Accessed on 8th March 2021]