Should a patient with type 2 diabetes mellitus (T2DM) experiencing hyperglycemia post-operatively take an extra dose of Gliclazide (Gliclazide) or Novorapid (Insulin Aspart)?

From the Guidelines

For a type 2 diabetic experiencing a post-operative blood glucose spike to 17 mmol/L, taking a rapid-acting insulin like NovoRapid is generally more appropriate than an extra dose of gliclazide. The recommended approach would be to administer a correction dose of NovoRapid based on the individual's insulin sensitivity factor (typically 1-2 units for every 2-3 mmol/L above target) as suggested by the latest guidelines 1. Gliclazide, being a sulfonylurea, works more slowly by stimulating insulin release from the pancreas and would not address the immediate high glucose effectively. Additionally, taking extra gliclazide could potentially cause prolonged hypoglycemia hours later. Some key points to consider in this scenario include:

• Monitoring blood glucose at least every 2–4 h while the individual takes nothing by mouth and administering short- or rapid-acting insulin as needed 1.
• Stricter perioperative glycemic goals are not advised, as perioperative glycemic goals stricter than 80–180 mg/dL (4.4–10.0 mmol/L) may not improve outcomes and are associated with increased hypoglycemia 1.
• The use of basal insulin plus pre-meal short- or rapid-acting insulin (basal-bolus) coverage has been associated with improved glycemic outcomes and lower rates of perioperative complications compared with the reactive, correction-only short- or rapid-acting insulin coverage alone with no basal insulin dosing 1. The rapid onset of NovoRapid (15-30 minutes) makes it suitable for managing acute hyperglycemia, while its shorter duration (3-5 hours) reduces the risk of delayed hypoglycemia. Post-operative stress and inflammation often cause temporary insulin resistance, making direct insulin administration more effective. However, the exact dosing should be determined based on the individual's usual insulin sensitivity, meal plans, and specific medical advice from their healthcare provider.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Management of Post-Operative Hyperglycemia in Type 2 Diabetes

• The management of post-operative hyperglycemia in patients with type 2 diabetes is crucial to prevent complications and promote recovery 2.
• According to the EADSG Guidelines, insulin therapy is indicated in patients with type 2 diabetes mellitus (T2DM) in cases of acute illness or surgery, among other conditions 2.
• The guidelines suggest that insulin is considered alone or in combination with oral agents when HbA1c is ≥ 7.5% (≥ 58 mmol/mol), and is essential for treatment in those with HbA1c ≥ 10% (≥ 86 mmol/mol) 2.

Choice of Insulin

• For postprandial glucose control, rapid-acting or short-acting (bolus or prandial) insulin can be added at mealtime 2.
• Novorapid (insulin aspart) is a rapid-acting insulin analog that can be used to control prandial glucose levels as part of basal-bolus therapy 3.
• Studies have shown that insulin aspart provides effective postprandial glucose control with lower rates of hypoglycemia compared to human soluble insulin 3, 4.

Adjusting Insulin Dose

• The decision to take an extra dose of gliclazide or novorapid should be based on the patient's individual needs and glucose monitoring results.
• Fasting plasma glucose (FPG) values should be used to titrate basal insulin, whereas both FPG and postprandial glucose (PPG) values should be used to titrate mealtime insulin 2.
• In the context of post-operative hyperglycemia, the patient's glucose levels should be closely monitored, and insulin doses adjusted accordingly to achieve optimal glucose control.

Specific Considerations for Post-Operative Hyperglycemia

• A study comparing Fiasp (ultrarapid-acting insulin) with Novolog (insulin aspart) in hospitalized patients with type 2 diabetes found that Fiasp provided noninferior postprandial glucose control with no increase in rates of hypoglycemia 5.
• Another study evaluating the efficacy and safety of fast-acting insulin aspart compared with insulin aspart in adults with type 2 diabetes found that fast-acting insulin aspart provided superior postprandial glucose control and a lower rate of severe or blood glucose-confirmed hypoglycemia 4.