Diabetes Overview

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

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 monographs.

When reducing insulin doses round to the nearest whole unit.

Regimen	Day before procedure*	Day of procedure*
ONCE daily (in the MORNING)	No dose change	Take 80% of usual dose
ONCE daily (at LUNCHTIME)	Take 80% of usual dose	Check CBG on admission
ONCE daily (in the EVENING)	Take 80% of usual dose	Check 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 monographs.

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

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 monographs.

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

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 monographs.

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)
-	Acarbose	Continue	Omit morning dose if nil by mouth	Take 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
Meglitinides	Nateglinide Repaglinide	Continue	Omit morning dose if nil by mouth	Take 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
-	Pioglitazone	Continue	Continue	Continue
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)

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®	Continue	Continue	Continue
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 dose	Omit dose	Omit dose

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]