DIABETES; surgery

Question 1

What drugs can be taken as normal during peri-operative period?

Answer 1

Pioglitazone
DDP4i

Question 2

How should insulin be given on the day before and the day of surgery?

Answer 2

Day before;
given insulin as normal except long acting insulin;
20% reduced dose

Day of and throughout intra perioperative period;
Once daily long acting should be given at 20% reduction.

ALL other insulins should be stopped until patient is eating and drinking during surgery.

Question 3

When insulin is given during surgery, what should be stopped?

Answer 3

Acarbose, meglitinides , sulfonylureas, pioglitazone, DDP4i and SGLT2 must be stopped once insulin infusion is commenced and NOT restated until patient is eating and drinking again as normal.

Question 4

When would SGLT2i be stopped?

Answer 4

Stopped in the day of surgery and not restarted until patient is stable. Their use during periods of dehydration and acute illness is associated with increased risk of DKA.

Question 5

When should sulfonylureas be stopped and why?

Answer 5

They have an increased risk of hypoglycaemia esp during fasted stated so should be stopped DAY OF surgery and not started until the patient is eating and drinking again.

Question 6

When should metformin be stopped and why?

Answer 6

Metformin is renally excreted, renal impairment may lead to accumulation and lactic acidosis during surgery.

If only one meal will be missed during surgery and the patient has an eGFR greater than 60mL/minute/1.73m2 and a low risk of AKI, it may possible to continue metformin during the peri-operative period – just the lunchtime dose should be omitted if the usual dose is TDS.

If the patient will miss more than one meal or there is a significant risk of developing an AKI. Metformin should be stopped when the pre-operative fast begins.

Metformin should not be recommenced until the patient is eating and drinking again + normal renal function is confirmed.