From the Guidelines
To minimize perioperative complications in diabetic patients, it is crucial to hold certain diabetes medications prior to surgery, as recommended by the most recent guidelines 1. The medications that should be held include:
- Metformin, which should be held on the day of surgery 1
- SGLT2 inhibitors, which should be discontinued 3-4 days before surgery 1
- Other oral glucose-lowering agents, which should be held the morning of surgery or procedure 1
- Insulin dose reductions, including NPH insulin to one-half of the dose or long-acting basal insulin analogs 1 It is essential to note that these recommendations are based on the latest evidence and guidelines, which prioritize minimizing the risk of complications, such as hypoglycemia, hyperglycemia, and diabetic ketoacidosis, during the perioperative period. Key considerations for perioperative care in diabetic patients include:
- Performing a preoperative risk assessment for patients with high-risk conditions, such as ischemic heart disease, autonomic neuropathy, or renal failure 1
- Targeting an A1C goal of <8% (<64.0 mmol/L) whenever possible for elective surgeries 1
- Maintaining a blood glucose goal of 100-180 mg/dL (5.6-10.0 mmol/L) within 4 hours of surgery 1 By following these guidelines and holding the recommended diabetes medications prior to surgery, healthcare providers can help minimize the risk of perioperative complications and improve outcomes for diabetic patients.
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 glucose control, and the type of surgery.
- According to 3, the Society for Ambulatory Anesthesia recommends holding certain oral hypoglycemic agents and adjusting home insulin regimens before ambulatory surgery.
- The management of preoperative oral hypoglycemic agents and home insulins is crucial to prevent hypoglycemia and hyperglycemia during the perioperative period 3.
- However, there is limited evidence on the optimal management of diabetes medications in the outpatient setting, and more research is needed to determine the best approach 4.
Preoperative Evaluation and Management
A thorough preoperative evaluation is essential to determine the best course of action for managing diabetes medications before surgery.
- The evaluation should include an assessment of the patient's usual level of glucose control, self-management skills, and history of hypoglycemia 5.
- Clear patient instructions and frequent blood glucose monitoring during the perioperative period can help prevent adverse outcomes 6.
- The use of effective strategies for insulin initiation and titration can also help achieve optimal glucose control 6.
Recommendations for Specific Medications
While there is no specific guidance on which diabetes medications to hold prior to surgery, the following recommendations can be made:
- Metformin, a commonly used oral hypoglycemic agent, may need to be held before surgery to prevent lactic acidosis 3.
- Insulin regimens may need to be adjusted before surgery to prevent hypoglycemia and hyperglycemia 3.
- Other diabetes medications, such as sulfonylureas and meglitinides, may also need to be held or adjusted before surgery, depending on the patient's individual needs and glucose control 3.