Lantus® [insulin glargine], Toujeo [insulin glargine], Levemir® [insulin detemir], Tresiba® [insulin degludec], Insulatard® [human insulin], Humulin® I [human insulin], Insuman® Basal [human insulin], Suliqua® [insulin glargine with lixisenatide], Xultophy® [insulin degludec with liraglutide]
[This monograph covers ONCE daily injections of insulin – for TWICE daily or THREE, FOUR or FIVE daily injections see separate monographs as advice is dependent on the regime used]
Issues for Surgery
Hypoglycaemia if continued during nil by mouth period.
Increased risk of post-operative infection and delayed wound healing due to poor glycaemic control if discontinued.
Advice in the Perioperative period
Insulin products are classified according to their duration of action and it is important to understand the type of insulin and the regimen the patient is on in relation to the advice to be given perioperatively. Confirm with the patient the exact name, strength, dose, frequency and preparation of insulin(s) that they are using (see Further Information).
See figure 1 below.
Figure 1 – Management of ONCE daily insulin in the Perioperative Period1
Combination Products: -
Consideration should be given to prescribing the components of combination products as separate medicines perioperatively.
The advice given above can be applied to patients presenting for emergency surgery. However, it must be remembered that these patients are high risk and are likely to require intravenous insulin infusion1.
Commence variable rate intravenous insulin infusion (VRIII) perioperatively where indicated, with the patient’s ONCE daily insulin continued at 80% of their usual pre-operative dose1 (see figure 1 above and Further Information).
Ensure emergency treatment of hypoglycaemia is prescribed i.e. Glucogel® and 20% dextrose. Rapid acting insulin should also be prescribed1, 2.
Encourage an early return to normal eating and drinking (as deemed appropriate by the Surgical Team), facilitating return to the patient’s usual diabetic regimen1. The insulin dose(s) may need adjusting, as insulin requirements can change due to post-operative stress, infection or altered food intake – monitor blood glucose levels and seek advice from specialist diabetes team if necessary1, 2.
Interaction(s) with Common Anaesthetic Agents
Reduction in Blood-Glucose Lowering Effect
Substances that may reduce the blood-glucose-lowering effect of insulin include sympathomimetics (e.g. epinephrine / adrenaline)3, 4, 5, 6, 7, 8, 9.
Interaction(s) with other Common Medicines used in the Perioperative Period
Enhancement of Blood-Glucose Lowering Effect
Substances that may enhance the blood-glucose lowering effect of insulin and increase susceptibility to hypoglycaemia include sulphonamide antibiotics (e.g. co-trimoxazole)3, 4, 5, 7, 8, 9, 10.
Reduction of Blood-Glucose Lowering Effect
Corticosteroids can reduce the blood-glucose-lowering effect of insulin4, 5, 6, 7, 8, 9, 10, 11. Clinically important hyperglycaemia has been seen12. Monitor blood glucose concentrations closely when corticosteroids are given to patients with diabetes12.
Octreotide may either increase or decrease insulin requirements 5, 6, 8, 9, 10.
Types of Insulin
In general, ONCE daily preparations of insulin are long-acting preparations. They mimic endogenous basal insulin secretion with a prolonged duration of action (may be up to 36 hours) and are usually taken once daily, although in some cases twice daily dosing may be used depending on individual requirements2.
Safe Prescribing of Insulin
European Medicines Agency – Guidance on prevention of medication errors with high-strength insulins13
A high-strength insulin is a medicine that contains insulin at a concentration of more than the standard 100 units/ml. There are differences in the way high-strength insulin products are used compared with existing insulin formulations of standard-strength and there is therefore a risk of medication errors and accidental mix-up.
Advice for Healthcare Professionals: -
Lantus® (insulin glargine 100 units/ml) and Toujeo® (insulin glargine 300 units/ml) are NOT bioequivalent and are NOT directly interchangeable3, 5.
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. Patients expected to miss more than one meal should have VRIII1.
VRIII is the preferred method of controlling serum glucose for most patients undergoing emergency surgery1.