Abasaglar® [insulin glargine], Humulin® I [isophane insulin], Insulatard® [isophane insulin], Insuman® Basal [isophane insulin], Lantus® [insulin glargine], Levemir® [insulin detemir], Semglee® [insulin glargine], Suliqua® [insulin glargine with lixisenatide], Tresiba® [insulin degludec], Toujeo® [insulin glargine], Xultophy® [insulin degludec with liraglutide]
[This monograph covers LONG-ACTING insulin – the advice is the same regardless of whether it is part of a basal-bolus regimen in type 1 diabetes or monotherapy / add-on therapy for type 2 diabetes]
Issues for Surgery
Increased risk of post-operative infection and delayed wound healing due to poor glycaemic control if discontinued.
Increased risk of Diabetic Ketoacidosis (DKA) if discontinued, particularly in patients with type 1 diabetes.
Advice in the Perioperative period
Continue, but at a reduced dose (including combination products containing Glucagon-Like Peptide 1 (GLP-1) receptor agonists) - see figure 1 below for details of dose reduction.
When reducing insulin doses round to the nearest unit.
Figure 1 – Management of LONG-ACTING insulin in the Perioperative Period1
Combination Products: -
The doses of Suliqua® and Xultophy® are expressed in terms of ‘dose steps’ (where 10 dose steps refers to 10 units of insulin).
Consideration should be given to prescribing the components of combination products as separate medicines perioperatively.
Patients undergoing Bariatric Surgery
Patients with type 2 diabetes mellitus commencing on liver reduction diet (LRD): Give 50% of usual dose when LRD commences, with close monitoring of CBG2 (see Further Information). When reducing insulin doses round to the nearest unit. For patients who are taking combination products, the long-acting insulin should be prescribed separately perioperatively so that adjustment to the insulin dose can be made. See also Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists monograph .
Patients with type 2 diabetes mellitus not following a LRD: Follow the advice in figure 1 above for Elective Surgery.
Ensure emergency treatment of hypoglycaemia is prescribed i.e. Glucogel® and 20% dextrose. Rapid acting insulin should also be prescribed1, 3.
Patients undergoing Bariatric Surgery
Patients with type 1 diabetes mellitus should be reviewed by the Diabetes Specialist Team post-operatively.
Patients with type 2 diabetes should initially withhold their long-acting insulin post-operatively. Blood glucose should be monitored until eating habits and food intake stabilises2. If there is a need to recommence long-acting insulin post-operatively the dose should be tapered on discharge with strict blood glucose monitoring to avoid hypoglycaemia. Patients should have their need for ongoing pharmacological management of their diabetes reviewed by their General Practitioner / Bariatric Surgical Team.
Interaction(s) with Common Anaesthetic Agents
Interaction(s) with other Common Medicines used in the Perioperative Period
Reduction of Blood-Glucose Lowering Effect
Somatostatin analogues (octreotide and possibly lanreotide) may either increase or decrease the insulin requirements5, 7, 9, 10, 11 but most patients with type 1 diabetes are likely to require a reduction in insulin dose, with some studies suggesting a potential reduction of 50% in patients taking concomitant octreotide12, 13. Monitor CBG when somatostatin analogues are given to patients with diabetes13.
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 interchangeable4, 6.
Patients and nursing staff should be reminded of the importance of rotating injection sites within the same body region to reduce or prevent the risk of cutaneous amyloidosis and other skin reactions; injecting into an affected ‘lumpy’ area may reduce the effectiveness of insulin3.
Continue long-acting insulin at 80% of usual dose during treatment with VRIII to prevent hyperglycaemia and ketosis on cessation of VRIII1. In patients with type 1 diabetes do not discontinue VRIII unless patient has received alternative subcutaneous insulin within the last 30 minutes1.
Liver Reduction Diet (LRD)