For further information on individual agents, please refer to individual monographs
NB: For advice on management of Diabetic Medication in patients undergoing Bariatric Surgery - see individual medication 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 Administration | Brands of Insulin | Day before Operation | Day of Surgery | If VRIII being used | |
| Morning Operation | Afternoon 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 dose | Check CBG on admission | |||
| ONCE Daily (in the evening) | Give 80% of usual dose | Check CBG on admission | |||
| TWICE Daily | Take morning dose as usual but give 80% of usual evening dose | Give 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.
| Regimen | Brands of Insulin | Day before Operation | Day of Surgery | If VRIII being used | |
| Morning Operation | Afternoon Operation | ||||
| TWICE Daily | Humalog Mix® 25 Humalog Mix® 50 Humulin® M3 Hypurin Porcine® 30/70 mix Insuman Comb® 15 Insuman Comb® 25 Insuman Comb® 50 NovoMix® 30 | No dose change | Halve 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 Daily | Halve 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.
| Regimen | Brands of Insulin | Day before Operation | Day of Surgery | If VRIII being used | |
| Morning Operation | Afternoon Operation | ||||
| TWICE Daily | Short-acting Actrapid® Apidra® Fiasp® Humalog® Humulin® S Hypurin® Porcine Neutral Insuman® Infusat Insuman® Rapid, NovoRapid® Intermediate-acting Humulin® I Hypurin® Porcine Isophane Insulatard® Insuman® Basal | No dose change | Calculate 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.
| Regimen | Brands of Insulin | Day before Operation | Day of Surgery | If VRIII being used | |
| Morning Operation | Afternoon Operation | ||||
| TWO to FOUR injections daily with meals | Actrapid® Apidra® Fiasp® Humalog® Humulin® R Humulin® S Hypurin® Porcine Neutral Insuman® Infusat Insuman® Rapid Lyumjev NovoRapid® | No dose change | Omit 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 | Examples | Morning operation | Afternoon operation | Post-operative advice |
| Acarbose | - | Omit morning dose if nil by mouth | Take morning dose if eating | Restart once eating and drinking normally and VRIII (if used) has been stopped |
| DDP IV inhibitors* | Alogliptin Linagliptin Saxagliptin Sitagliptin Vildagliptin | Continue | Restart once eating and drinking normally and VRIII (if used) has been stopped | |
| GLP-1 receptor analogues | Albiglutide Dulaglutide Exenatide Exenatide MR Liraglutide Lixisenatide | Continue | Continue even if VRIII used | |
| Meglitinides | Nateglinide Repaglinide | Omit morning dose if nil by mouth | Take morning dose if eating | Restart 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* | - | Continue | Restart once eating and drinking normally and VRIII (if used) has been stopped | |
| SGLT2 inhibitors* | Canagliflozin Dapagliflozin Empagliflozin Ertugliflozin | 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 | |
| Sulfonylureas | Glibenclamide Gliclazide Gliclazide MR Glimepiride Glipizide Tolbutamide | Omit morning dose | Omit morning and afternoon dose | Restart 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 operation | Afternoon operation | Post-operative advice |
| Metformin+ pioglitazone | Competact® | Continue* | Once eating and drinking normally and VRIII (if used) has been stopped, check eGFR and follow advice in Metformin monograph | |
| Metformin+ DPP-IV Inhibitors | Eucreas® 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 Inhibitors | Synjardy® 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 Inhibitors | Glyxambi® 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]