UK Clinical Pharmacy Association

Diabetes - Overview

For patient who who will have restricted dietary intake pre-operatively i.e. patients undertaking the liver reduction diet (LRD) undergoing bariatric surgery, please see individual drug records

Management of insulin in the perioperative period 

When reducing insulin doses round to the nearest whole unit.

Management of long-acting insulin in the perioperative period

Brands: Abasaglar®, Humulin I®, Insulatard®, Lantus®, Levemir®, Semglee®, Toujeo®, Tresiba®, Suliqua®*, Xultophy®*

* in combination with glucagon-like peptide-1 (GLP-1) receptor agonist. The doses for both Suliqua® and Xultophy® are expressed in terms of ‘dose steps’, where 10 dose steps refers to 10 units of insulin.

For further details please consult the individual drug records.

When reducing insulin doses round to the nearest whole unit.

RegimenDay before procedure*Day of procedure*
ONCE daily
(in the MORNING)
No dose changeTake 80% of usual dose
ONCE daily
(at LUNCHTIME)
Take 80% of usual doseCheck CBG on admission
ONCE daily
(in the EVENING)
Take 80% of usual doseCheck CBG on admission

TWICE daily
Take morning dose as usual and
take 80% of usual evening dose
Take 80% of usual
morning dose

* Advice is the same for MORNING and AFTERNOON procedures

Management of premixed insulin in the perioperative period

Brands: Humalog Mix® 25, Humalog Mix® 50, Humulin® M3, Hypurin Porcine® 30/70 mix, NovoMix® 30

For further details please consult the individual drug records.

When reducing insulin doses round to the nearest whole unit.



Regimen


Day before procedure


Day of procedure*

TWICE daily

No dose change
Halve usual morning dose

Check capillary blood glucose (CBG)
on admission


THREE times a day


No dose change
Halve usual morning dose

Check CBG on admission

Omit lunchtime dose

* Advice is the same for MORNING and AFTERNOON procedure

Management of self-mixed insulin in the perioperative period 

Self-mixed insulin refers to two different types of insulin (usually a short-acting and intermediate-acting insulin) combined by the patient into one injection.

Brands of short-acting insulin: Actrapid®, Apidra®, Fiasp®, Humalog®, Humulin® S, Hypurin® Porcine Neutral, NovoRapid® 

Brands of Intermediate-acting insulin: Humulin® I, Hypurin® Porcine Isophane, Insulatard®

For further details please consult the individual drug records.

When reducing insulin doses round to the nearest whole unit.


Regimen
Day before procedure
Day of procedure*

TWICE daily

No dose change
Calculate the total dose of both morning insulins and give half of this total dose as intermediate-acting insulin only in the morning

Check capillary blood glucose (CBG) on admission

* Advice is the same for MORNING and AFTERNOON procedure

Management of short-acting insulin in the perioperative period

Brands: Actrapid®, Apidra, Fiasp, Humalog®, Humulin® R, Hypurin® Porcine Neutral, Lyumjev, NovoRapid®

For further details please consult the individual drug records.

When reducing insulin doses round to the nearest whole 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

Management of non-insulin diabetic medication in the perioperative period

For combination products, see below for perioperative medication advice




Drug Class



Drugs in class


Day before procedure
Day of procedure
(MORNING procedure)

Day of procedure
(AFTERNOON procedure)
-AcarboseContinueOmit morning dose if nil by mouthTake morning dose if eating


DDP IV inhibitors*
Alogliptin
Linaglitpin
Saxagliptin
Sitagliptin
Vildagliptin


Continue


Continue


Continue


GLP-1 receptor analogues
Dulaglutide
Exenatide (inc. MR preparation)
Liraglutide
Lixisenatide


Continue


Continue


Continue
MeglitinidesNateglinide
Repaglinide
ContinueOmit morning dose if nil by mouthTake morning dose if eating
-Metformin**
(inc. MR preparations)

ONCE or TWICE daily

THREE times daily





Continue


Continue




Continue


Omit lunchtime dose




Continue


Omit lunchtime dose
-PioglitazoneContinueContinueContinue

SGLT-2 inhibitors*
Canagliflozin
Dapagliflozin
Empagliflozin
Ertugliflozin

Omit dose

Omit dose

Omit dose


Sulfonylureas
Glibenclamide
Gliclazide (inc. MR preparations)
Glimepiride
Glipizide
Tolbutamide


Continue


Omit morning dose


Omit morning and afternoon dose(s)
 

* If restricted dietary intake expected (i.e. liver reduction diet prior to bariatric surgery), see individual drug records

**If eGFR<60 and contrast media is planned, omit metformin on the day of surgery and for 48 hours post-operatively

Combination products

Consideration should be given to prescribing the individual components separately so that the usual perioperative advice can be followed for each component (as per the individual drug records). This is particularly important for combination products containing SGLT-2 inhibitors which require a longer period of treatment interruption.

If this is not possible, see below for perioperative advice for medications containing more than one non-insulin diabetic medication.




Drug
Combination




Brand



Day before procedure


Day of procedure
(MORNING procedure)


Day of procedure
(AFTERNOON procedure)
Metformin
and
Pioglitazone*
Competact®ContinueContinueContinue
Metformin
and
DDP-IV inhibitor*
(see above for drugs in class)
Eucreas®
Janumet®
Jentadueto®
Komboglyze®
Vipdomet®


Continue


Continue


Continue
Metformin
and
SGLT-2 inhibitor
Synjardy®
Vokanamet®
Xigduo®

Omit dose


Omit dose


Omit dose

SGLT-2 inhibitor
and
DDP-IV inhibitor
Glyxambi®
Qtern®
Omit doseOmit doseOmit dose

*If eGFR<60 and contrast media is planned, omit metformin combination product on the day of surgery and for 48 hours post-operatively

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]