Meglitinides

Nateglinide, Repaglinide

  Issues for Surgery

Increased risk of post-operative infection and delayed wound healing due to poor glycaemic control if omitted.

Hypoglycaemia if continued during nil by mouth (NBM) period.

  Advice in the Perioperative period

Elective Surgery

Meglitinides should be taken as normal the day prior to surgery¹.

Morning Surgery
Omit morning dose if nil by mouth^{1, 2}.

Afternoon Surgery
Take morning dose if eating^{1, 2}.

Emergency Surgery

In the event of emergency surgery and the patient has already taken their meglitinide dose monitor capillary blood glucose (CBG) levels closely and treat any hypoglycaemia accordingly.

Perioperative Considerations

Commence variable rate intravenous insulin infusion (VRIII) perioperatively where indicated (see Further Information) and omit meglitinide during VRIII treatment¹.

Ensure emergency treatment of hypoglycaemia is prescribed i.e. Glucogel^® and 20% dextrose. Rapid acting insulin should also be prescribed^{1, 2}.

Post-operative Advice

Restart once eating and drinking normally and VRIII (where applicable) has been stopped¹.

  Interaction(s) with Common Anaesthetic Agents

None^{2, 3, 4, 5, 6}.

  Interaction(s) with other Common Medicines used in the Perioperative Period

Non-Steroidal Anti-inflammatory Drugs (NSAIDs)

Caution with concomitant use of NSAIDs – may enhance the hypoglycaemic effect of meglitinides^{3, 4}.

Antibiotics

Clarithromycin and trimethoprim slightly increase the exposure to repaglinide^{2, 4, 5, 6}. As infections can increase blood glucose concentrations this is not thought to be clinically significant; however, there are case reports of hypoglycaemia with concurrent use⁶. If concurrent use of clarithromycin, erythromycin, trimethoprim or co-trimoxazole is deemed necessary – monitor CBG closely and adjust repaglinide dose if necessary⁶.

  Further Information

VRIII

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 (CBG >12mmol/L)¹.

  References

1. 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 8^th March 2021]
2. Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 27^th February 2021]
3. Summary of Product Characteristics - Starlix^® (nateglinide). Novartis Pharmaceuticals UK Ltd. Accessed via www.medicines.org.uk 27/02/2021 [date of revision of the text June 2015]
4. Summary of Product Characteristics - Prandin^® (repaglinide) 1mg tablets. Novo Nordisk Limited. Accessed via www.medicines.org.uk 27/02/2021 [date of revision of the text May 2016]
5. Repaglinide. In: Brayfield A (Ed), Martindale: The Complete Drug Reference. London: The Royal Pharmaceutical Society of Great Britain. Electronic version. Truven Health Analytics, Greenwood Village, Colorado, USA. http://www.micromedexsolutions.com [Accessed 1^st March 2021]
6. Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 27^th February 2021]