Actrapid® [human insulin], Apidra® [insulin glulisine], Fiasp® [insulin aspart], Humalog® [insulin lispro], Humulin® R [human insulin], Humulin® S [human insulin], Hypurin® Porcine Neutral [porcine animal insulin], Insuman® Infusat [human insulin], Insuman® Rapid [human insulin], Lyumjev® [insulin lispro], NovoRapid®[insulin aspart], Trurapi® [insulin aspart]
Issues for Surgery
Increased risk of post-operative infection and delayed wound healing due to poor glycaemic control if discontinued.
Advice in the Perioperative period
Omit doses whilst not eating - see figure 1 below for details.
When reducing insulin doses round to the nearest unit.
Figure 1 – Management of SHORT-ACTING insulin in the perioperative period1
Patients undergoing Bariatric Surgery
Patients with type 2 diabetes mellitus commencing on liver reduction diet (LRD): Stop regular administration of short-acting insulin when LRD commences and monitor CBG closely. If CBG >15mmol/L give 50% of usual dose of short-acting insulin as a rescue / correction dose2 (see Further Information). When reducing insulin doses round to the nearest unit.
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 discontinue their short-acting insulin post-operatively. Blood glucose should be monitored until eating habits and food intake stabilises2, if long-acting insulin is recommenced post-operatively follow advice in Long-acting Insulin monograph. 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 increase or decrease insulin requirements4, 6, 7, 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 octreotide6, 7. Monitor CBG when somatostatin analogues are given to patients with diabetes7.
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: -
Humulin® R (500 units/ml) is a HIGH strength insulin that is not currently licensed in the UK. It is imported from the USA2. It is NOT interchangeable with other short-acting insulin preparations. It is usually prescribed for patients with high insulin resistance and such patients should be referred to the Diabetes Team for a specialist management plan.
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.
For patients on basal-bolus regimen, continue long-acting insulin at 80% of usual dose during treatment with VRIII to prevent hyperglycaemia and ketosis on cessation of VRIII, if not usually prescribed long-acting insulin commence at dose of 0.2 units per kilogram1. 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)