Brands of short acting insulin
Actrapid®, Apidra®, Fiasp®, Humalog®, Humulin® R, Humulin® S, Hypurin® Porcine Neutral, Lyumjev®, NovoRapid®, Trurapi®
Issues for surgery
Increased risk of post-operative infection and delayed wound healing due to poor glycaemic control if discontinued.
Hypoglycaemia if continued during nil by mouth period / during liver reduction diet (LRD) in patients undergoing Bariatric Surgery.
Advice in the perioperative period
Insulin products are classified according to their duration of action and it is important to understand the type of insulin the patient is on in relation to the advice to be given perioperatively. Confirm with the patient the exact name, strength, dose, frequency and preparation of insulin(s) that they are using (see Further information).
Elective surgery
Omit doses whilst not eating - see table for details.
Except patients undergoing bariatric surgery – see below.
When reducing insulin doses round to the nearest unit.
| Regimen | Day before procedure | Day of procedure (MORNING procedure) | Day of procedure (AFTERNOON procedure) |
|---|---|---|---|
Multiple daily injections | No dose change | Omit morning dose if no breakfast eaten Check CBG on admission Omit lunchtime dose if not eating and drinking normally | Take usual morning dose with breakfast Omit lunchtime dose if not eating Check CBG on admission |
Patients undergoing surgery that requires liver reduction diet (LRD) (e.g. bariatric surgery, gallbladder surgery)
Patients with type 1 diabetes mellitus need an individualised management plan formulated with the diabetes specialist team.
For 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 greater than 15mmol/L give 50% of usual dose of short-acting insulin as a rescue / correction dose (see Further information). When reducing insulin doses round to the nearest unit.
For patients with type 2 diabetes mellitus not following a LRD: follow the advice above for elective surgery.
Emergency surgery
Monitor CBG, ketones, renal profile and lactate on admission to exclude diabetic ketoacidosis (DKA) or hyperosmolar hyperglycaemic state (HHS). The advice given above can be applied to patients presenting for emergency surgery; however, it must be remembered that these patients are high risk and are likely to require intravenous insulin infusion; either variable rate intravenous insulin infusion (VRIII), or in the case of DKA or HHS a fixed rate intravenous insulin infusion. Continue to monitor ketones if CBG greater than 13mmol/mol.
Perioperative considerations
Commence variable rate intravenous insulin infusion (VRIII) perioperatively where indicated and omit patient’s short-acting insulin during VRIII treatment. Patients on basal-bolus regimens should continue their long-acting insulin at 80% of the usual dose (see above and Further information). If not usually prescribed long-acting insulin commence at a dose of 0.2 units per kilogram.
Ensure emergency treatment of hypoglycaemia is prescribed, i.e. Glucogel® and 20% dextrose. Rapid acting insulin should also be prescribed.
Post-operative advice
Encourage an early return to normal eating and drinking (as deemed appropriate by the surgical team), facilitating return to the patient’s usual diabetic regimen. The insulin dose(s) may need adjusting, as insulin requirements can change due to post-operative stress, infection or altered food intake – monitor CBG levels and seek advice from specialist diabetes team if necessary.
Ideally, resume usual evening insulin if eating a normal meal. If eating a half or small meal give half usual dose. If not eating, ensure usual basal component of insulin regimen is still administered (see Insulin – Long acting).
If VRIII being used: Stop until eating and drinking but continue long-acting insulin at 80% of usual dose. (If not usually prescribed long-acting insulin commence at dose of 0.2 units per kilogram) (see Insulin – Long acting).
Patients undergoing bariatric surgery
Improved glycaemic control is expected because of reduced calorie intake, early satiety and weight loss following 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 stabilises; if long-acting insulin is recommenced post-operatively follow advice in Insulin – Long acting. Patients should have their need for ongoing pharmacological management of their diabetes reviewed by their GP or bariatric surgical team.
Interactions with common anaesthetic agents
Reduction of blood-glucose lowering effect
Substances that may reduce the blood-glucose-lowering effect of insulin include sympathomimetics (e.g. epinephrine / adrenaline).
Interactions with other common medicines used in the perioperative period
Enhancement of blood-glucose lowering effect
Substances that may enhance the blood-glucose lowering effect of insulin and increase susceptibility to hypoglycaemia include sulphonamide antibiotics (e.g. co-trimoxazole).
Reduction of blood-glucose lowering effect
Corticosteroids can reduce the blood-glucose-lowering effect of insulin. Clinically important hyperglycaemia has been seen. Monitor CBG closely when corticosteroids are given to patients with diabetes.
Somatostatin analogues (octreotide and possibly lanreotide) may increase or decrease insulin requirements, 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 octreotide. Monitor CBG when somatostatin analogues are given to patients with diabetes.
Further information
Safe prescribing and administration of insulin
European Medicines Agency – Guidance on prevention of medication errors with high-strength insulins
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:
- A syringe must NEVER be used to withdraw insulin from a pre-filled pen otherwise severe overdose can result
- Insulin must always be prescribed in units (spelled out in full) and include the dose frequency
- The strength of the insulin formulation should always be included in the prescription.
Humulin® R (500 units/ml) is a HIGH strength insulin that is not currently licensed in the UK. It is imported from the USA. 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 insulin.
Variable rate insulin infusion (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 in patients with type 1 diabetes who have not received their long-acting insulin, in patients with type 1 diabetes who are expected to miss more than one meal, if emergency surgery or in people with poorly controlled diabetes (HbA1c greater than 69mmol/mol)).
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 kilogram. In patients with type 1 diabetes mellitus do not discontinue VRIII unless patient has received alternative subcutaneous insulin within the last 30 minutes.
Liver reduction diet (LRD)
Most people needing bariatric surgery have a large, fatty liver which can cause difficulty for laparoscopic surgery, as the stomach cannot be easily accessed. The LRD typically starts 10 – 15 days prior to bariatric surgery and is based on low calories, in particular low carbohydrate and fat. This forces stored glycogen to be released from the liver (plus some water), making it softer, more flexible and easier to move. Due to the reduced calorie and carbohydrate intake, CBG levels will most likely be reduced. Patients are at increased risk of hypoglycaemia when short-acting insulin is continued during this period.
References
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 8th March 2021]
Busetto L, Dicker D, Azran C et al. Practical Recommendations of the Obesity Management Task Force of the European Association for the Study of Obesity for the Post-Bariatric Surgery Medical Management. Obesity Facts 2017;10:597 – 632. DOI: 10.1159/000481825
Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 1st March 2021]
Summary of Product Characteristics – Actrapid® (human insulin) 100 international units/ml, Solution for Injection in a vial. Novo Nordisk Limited. Accessed via www.medicines.org.uk 01/03/2021 [date of revision of the text October 2020]
Summary of Product Characteristics – Apidra® (insulin glulisine) SoloStar 100 Units/ml solution for injection in a pre-filled pen. SANOFI. Accessed via www.medicines.org.uk 01/03/2021 [date of revision of the text September 2020]
Insulin. In: Brayfield A (Ed), Martindale: The Complete Drug Reference. London: The Royal Pharmaceutical Society of Great Britain. http://www.medicinescomplete.com [Accessed 1st March 2021]
Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://www.medicinescomplete.com [Accessed 1st March 2021]
European Medicines Agency: Guidance on prevention of medication errors with high-strength insulins. 27 November 2015. Available at: www.ema.europa.eu [Accessed 1st March 2021)