What are the recommendations for administering insulin, long-acting insulin, and other diabetic medications on the morning of surgery?

From the Guidelines

For diabetic patients undergoing surgery, the morning insulin and medication regimen should be adjusted based on the type of diabetes medication and surgical timing, with long-acting insulin given at 75-80% of the usual dose, and other oral glucose-lowering agents held the morning of surgery or procedure, as recommended by the most recent guidelines 1. The adjustment of insulin and medication regimens is crucial to maintain glycemic control and minimize the risks of hypo- and hyperglycemia during the perioperative period.

• Long-acting insulin (such as glargine/Lantus, detemir/Levemir, or degludec/Tresiba) should generally be given at 75-80% of the usual dose on the morning of surgery to provide basal coverage while reducing hypoglycemia risk, as suggested by the latest guidelines 1.
• Intermediate-acting insulin (NPH) should be reduced to one-half of the dose, as recommended by the guidelines 1.
• Short-acting or rapid-acting insulin (regular, lispro, aspart, glulisine) should be held if the patient is fasting, and administered as needed to maintain blood glucose within the target range of 100-180 mg/dL, as recommended by the guidelines 1.
• For oral medications, metformin should be held on the day of surgery, and SGLT2 inhibitors should be discontinued 3-4 days before surgery, as recommended by the guidelines 1.
• GLP-1 agonists can typically be continued for scheduled procedures but may be held if there are concerns about delayed gastric emptying, although there is little data on their safe use in the perioperative period, as noted by the guidelines 1, 2.
• Blood glucose should be monitored frequently before, during, and after surgery, with a target range of 100-180 mg/dL, and supplemental insulin given as needed, as recommended by the guidelines 1, 2. The guidelines emphasize the importance of individualized care and consideration of the patient's specific needs and medical history when making decisions about insulin and medication regimens during the perioperative period, as noted by the guidelines 1, 2.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Individualize dosage based on metabolic needs, blood glucose monitoring, glycemic control, type of diabetes, and prior insulin use. Administer subcutaneously into the abdominal area, thigh, or deltoid once daily at any time of day, but at the same time every day. For patients treated with Levemir once-daily, the dose should be administered with the evening meal or at bedtime For patients who require twice-daily dosing for effective blood glucose control, the evening dose can be administered either with the evening meal, at bedtime, or 12 hours after the morning dose. Subcutaneous Injection Administer within 15 minutes before a meal or immediately after a meal. Use in a regimen with an intermediate- or long-acting insulin.

The FDA drug label does not provide specific recommendations for giving insulin, long-acting insulin, and other diabetic medication on the morning of surgery. 3, 4, and 5 do not directly address the question of medication administration on the morning of surgery.

From the Research

Recommendations for Diabetic Medication on the Morning of Surgery

There are no specific recommendations provided in the given studies regarding the administration of insulin, long-acting insulin, and other diabetic medications on the morning of surgery.

General Guidance on Diabetic Medications

• The studies primarily focus on the comparison of different antidiabetic medications, such as SGLT2 inhibitors, metformin, and sulfonylureas, in terms of their efficacy and safety in patients with type 2 diabetes 6, 7, 8, 9, 10.
• SGLT2 inhibitors have been shown to be effective in reducing blood glucose levels, with added benefits in patients with obesity, renal disease, heart failure, and cardiovascular disease 6, 8, 10.
• Metformin is a commonly used antidiabetic medication, and its mechanism of action is based on reducing glucose production in the liver, decreasing insulin resistance, and increasing insulin sensitivity 7.
• The choice of antidiabetic medication depends on various factors, including the patient's medical history, renal function, and cardiovascular risk factors 7, 8, 10.

Considerations for Surgery

• There is no direct evidence provided in the studies to guide the administration of diabetic medications on the morning of surgery.
• However, it is generally recommended to consult with the patient's healthcare provider or anesthesiologist to determine the best course of action for managing diabetes on the day of surgery.