Alogliptin, Linagliptin, Saxagliptin, Sitagliptin, Vildagliptin
Issues for Surgery
Increased risk of post-operative infection and delayed wound healing due to poor glycaemic control if omitted.
Potential for hypoglycaemia when taken concomitantly with other blood glucose lowering medicines and continued during nil by mouth period.
Combination products containing Metformin – risk of lactic acidosis if continued (see Interaction(s) with other Common Medicines used in the Perioperative Period and Further Information).
Combination products containing Dapagliflozin or Empagliflozin– risk of diabetic ketoacidosis (DKA), volume depletion, hypotension and/or electrolyte disturbances if continued (see Further Information).
Advice in the Perioperative period
Elective and Emergency Surgery
DDP-IV Inhibitors should be taken as normal the day prior to surgery1.
Morning or Afternoon Surgery
Consideration should be given to prescribing the components of combination products as separate medicines perioperatively.
Commence variable rate intravenous insulin infusion (VRIII) perioperatively where indicated (see Further Information) and withhold DPP-IV Inhibitor during VRIII treatment1.
Ensure emergency treatment of hypoglycaemia is prescribed i.e. Glucogel® and 20% dextrose. Rapid also be prescribed1, 2.
Restart once eating and drinking normally and VRIII (where applicable) has been stopped1.
For combination products containing metformin – follow advice in Metformin monograph.
For combination products containing SGLT-2 Inhibitors – follow advice in Sodium Glucose Co-transporter 2 (SGLT-2) Inhibitors monograph.
Interaction(s) with Common Anaesthetic Agents
None for products containing DDP-IV Inhibitor alone2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14.
Combination products containing a SGLT-2 inhibitor can increase the risk of hypotension when used concomitantly with inhalational or intravenous anaesthetics2.
Interaction(s) with other Common Medicines used in the Perioperative Period
None for products containing DPP-IV Inhibitor alone2, 3, 5, 7, 10, 12.
Iodinated Contrast Agents
Caution with combination products containing metformin and concomitant use of iodinated contrast agents4, 6, 8,11, 13 – see Metformin monograph.
Non-Steroidal Anti-inflammatory Drugs (NSAIDs)
Caution with combination products containing metformin and concomitant use of NSAIDs4, 6, 8, 11, 13 – see Metformin monograph.
Combination products containing a SGLT-2 inhibitor can increase the risk of hypotension when used concomitantly with the antiemetics droperidol and prochlorperazine2.
Risk of lactic acidosis with combination products containing metformin4, 6, 8, 11, 13 – see Metformin monograph.
DKA, Volume Depletion, Hypotension and/or Electrolyte Imbalance
Risk of DKA, volume depletion, hypotension and/or electrolyte imbalance with combination product containing dapagliflozin or empagliflozin9,14 – see Sodium Glucose Co-transporter 2 (SGLT-2) Inhibitors monograph.
Patients with a planned short starvation period (no more than one missed meal in total) should be managed by modification of their usual diabetes medication, avoiding VRIII wherever possible (although VRIII may be necessary if emergency surgery or in people with poorly controlled diabetes (HbA1c >69mmol/mol))1. Patients with type 2 diabetes who are expected to miss more than one meal should have VRIII if they develop hyperglycaemia (capillary blood glucose (CBG) >12mmol/L)1.