Which diabetes medications, such as Metformin (Metformin), should be withheld prior to surgery in patients with diabetes mellitus?

From the Guidelines

To minimize risks and complications, metformin should be held on the day of surgery, SGLT2 inhibitors should be discontinued 3-4 days before surgery, and other oral glucose-lowering agents should be held the morning of surgery or procedure, as recommended by the most recent guidelines 1. When managing diabetes medications prior to surgery, it's crucial to consider the potential risks and benefits of each medication.

• Metformin, for example, should be held on the day of surgery due to the risk of lactic acidosis, especially in patients who may experience reduced kidney function during surgery.
• SGLT2 inhibitors, such as empagliflozin, dapagliflozin, and canagliflozin, should be discontinued 3-4 days before surgery to prevent euglycemic diabetic ketoacidosis.
• Other oral glucose-lowering agents, including sulfonylureas like glipizide and glyburide, should be held the morning of surgery or procedure to avoid hypoglycemia during the fasting period.
• For insulin regimens, basal insulin is typically continued at a reduced dose, while bolus insulin is held until the patient resumes eating, as supported by recent studies 1. The goal of these recommendations is to maintain glucose control while minimizing the risks of hypoglycemia, ketoacidosis, and other metabolic complications during the perioperative period when patients are fasting and experiencing surgical stress. Key considerations include:
• Preoperative risk assessment for patients with diabetes who are at high risk for ischemic heart disease and those with autonomic neuropathy or renal failure.
• Target blood glucose range in the perioperative period of 100-180 mg/dL (5.6-10.0 mmol/L) within 4 hours of surgery.
• Monitoring blood glucose at least every 2-4 hours while the patient is taking nothing by mouth and dosing with short- or rapid-acting insulin as needed, as outlined in the most recent guidelines 1.

From the FDA Drug Label

Do not take metformin hydrochloride tablets if you: ... are going to get an injection of dye or contrast agents for an x-ray procedure or if you are going to have surgery and not able to eat or drink much. In these situations, metformin hydrochloride tablets will need to be stopped for a short time. Key Points:

• Metformin should be held prior to surgery, especially if the patient is not able to eat or drink much.
• The decision to hold metformin should be made in consultation with the healthcare provider.
• The healthcare provider will advise when to stop and restart metformin hydrochloride tablets 2

From the Research

Diabetes Medications to Hold Prior to Surgery

The decision to hold diabetes medications prior to surgery depends on various factors, including the type of medication, the patient's level of control, and the type of surgery.

• Oral anti-hyperglycemic medications, other than sulfonylureas and SGLT2 inhibitors, can be continued safely perioperatively depending upon the type of surgery and the patient is expected to resume oral intake soon postoperatively 3.
• Sulfonylureas and SGLT2 inhibitors may need to be held prior to surgery due to the risk of hypoglycemia and other complications.
• Insulin regimens may need to be adjusted prior to surgery to prevent hyperglycemia and hypoglycemia 4, 5.

Considerations for Perioperative Management

When managing patients with diabetes in the perioperative period, several factors need to be considered, including:

• The patient's usual level of control and self-management skills 6.
• The occurrence of hypoglycemia and the risk of hyperglycemia 4, 5.
• The type and duration of surgery, as well as the patient's comorbidities and general health 3.
• The interaction of medications, both anti-diabetic and non-diabetic, and the potential for complications 3, 7.