Preoperative considerations for patients with diabetes

Figures & data

Table 2. Preoperative guidelines from international organizations.

Preoperative Practice	American Diabetes Association	Australian Diabetes Society	Centre for Perioperative Care
Reference	2	34	8
A1C assessment for elective cases	target is < 8%	Measure within the preceding 3 months (preferably within 4–6 weeks prior); target < 9%	3 months before DOS; target is < 8.5%
Referral to a diabetes specialist	For hospitalized patients with diabetes	A1C ≥ 8.5%	For patients with A1C > 8.5% or on insulin pump
DOS blood glucose assessment	Check the DOS; target range for perioperative period is 100–180 mg/dl (5.5–10 mmol/L) within 4 hours of surgery	Check the DOS; Target range perioepratively is 90–180 mg/dl (5–10 mmol/L); pregnancy 72–106 mg/dl (4–6 mmol/L) and requiring high target 135–216 mg/dl (7.5–12.5 mmol/L) such as emergency surgery with previous poor glycemic control, hypocalcemia unawareness, prolonged QT interval or autonomic neuropathy, and >75 years old	Check DOS; Target range perioperatively is 6-10 mmol/L with up to 12 mmol/L may be acceptable
Long-acting insulin	75–80% doses or insulin pump basal insulin based on the type of diabetes and clinical judgment the day of surgery	Insulin regimen should be continued up to and including the night before surgery except where bowel preparation is required Reduce basal insulin by 20% if with recent overnight hypoglycemia	Recommendations depend on the frequency and time of administration. Prior to the day of surgery, only the morning administration has no dose adjustment, all other time of frequency requires administration of 80% of usual dose. On the DOS, several recommendations noted; however, the usual dose in AM insulin decreased by 20%.
Intermediate-acting insulin or mixed insulin	Half NPH dose on morning of surgery	Calculate the total dose of all insulins for morning and lunch. For AM surgery: Half of the total insulin dose should be given as an intermediate acting insulin only in the morning. For PM surgery: half of the total insulin should be given as an intermediate acting insulin only in the morning. Half of the morning rapid-acting insulin can be given with a light breakfast.	Mixed insulin has no dose adjustment prior to the day of surgery. On the day of surgery, half the premixed insulin dose while self-mix insulin requires taking the half of the total dose of intermediate acting insulin.
Short-acting insulin		For morning surgery: Hold morning and lunch dose For afternoon surgery: Half of dose with light breakfast.	No dose adjustment necessary day before surgery. On DOS, omit dose if no breakfast for morning surgery while take usual dose with breakfast for afternoon/evening surgery
Oral agents and non-insulin injectables	Hold all on DOS, except for SGLT2i, stop 3–4 days before DOS and DOS	Hold all on DOS except SGLT-2 Inhibitors For all surgeries, including cases needing bowel preparation such as colonoscopy, stop SGLT2i 2 days before DOS and on DOS For minor surgeries without bowel preparation, only hold during DOS	Except for SGLT-2 inhibitors that is omitted on the day before surgery, all non-insulin diabetes medication are taken as usual a day before the surgery. Morning dose of acarbose, meglitinide, metformin, and sulfonylureas should be omitted on the DOS Take as normal pioglitazone, DPP-4 inhibitors, and daily GLP-1 receptor agonist on the day of surgery. SGLT-2 inhibitors are omitted on the day of surgery.

A1c = hemoglobin A1c, DOS = Date of Surgery, SGLT-2i = Sodium Glucose Transport 2 inhibitor.

Table 1. Pharmacological agents for glycemic control.

Class	Generic Name	Mechanism	Metabolism	Comments for Post- Surgery	Reference
Sulfonylurea Meglitinide	Glipizide Glimepiride Glyburide Glibenclamide Gliclazide Repaglinide Nateglinide	Stimulation of insulin secretion from pancreas by inhibition of K-ATP channel, provoking calcium influx into the β cell	Hepatically metabolized and renally excreted Glyburide and Glibenclamide very long half-life especially in elderly and renal dysfunction	Restart after food intake is resumed	[2,60,61]
Biguanide	Metformin	Inhibition of hepatic glucose production and intestinal absorption improves insulin sensitivity by increasing peripheral glucose uptake and utilization	Unmetabolized and renal excretion	Consideration if patient needs contrast dye or declining renal function Restart after 24 hours with stabilize renal function	[2,56–60]
Thiazolidinedione	Pioglitazone Rosiglitazone	Enhanced insulin sensitivity by activation of peroxisome proliferator-activated receptors – PPAR-γ	Metabolized with some renal excretion	Edema with increased risk of heart failure, fractures, weight gain Restart after food intake is resumed	[61,68–70]
Alpha-glucosidase inhibitor	Acarbose Miglitol Voglibose	Inhibition of intestinal glucose absorption	Low systemic bioavailablity	Restart after food intake is resumed	[66,68]
Dipeptidyl Peptidase-4 Inhibitors	Sitagliptin Saxagliptin Alogliptin Linagliptin Vildagliptin	Inhibition of endogenous GLP-1 degradation	Minimal metabolism, excreted by kidneys except Linagliptin	Restart after food intake is resumed	[61,68]
Sodium Glucose cotransporter 2 inhibitors(SGLT-2i)	Canaglifozin Dapagliflozin Empagliflozin Ertugliflozin	Inhibition of renal glucose reabsorption, promoting glucosuria	Metabolized via glucuronidation to inactive metabolites	Resume when hydrated and renal function stable	[62–67]
Glucagon like peptide-1 (GLP-1) Agonists	Exenatide Liraglutide Semaglutide Dulaglutide Lixisenatide	Activates GLP-1 receptor, increased insulin secretion, suppresses glucagon, delayed gastric emptying, increased satiety	Rapidly metabolized and inactivated by the enzyme dipeptidyl peptidase	Assure no nausea and vomiting and restart after food intake resumed.	[71–74]
Insulin	Variety	Work equally to endogenous insulin	Metabolized to amino acids	Basal insulin in reduced doses may be required and mealtime insulin can be restarted after food intake is resumed	[75–78]

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