What are the recommendations for managing diabetes perioperatively in surgical patients?

From the Guidelines

Perioperative diabetes management should prioritize maintaining blood glucose targets between 100-180 mg/dL (5.6-10.0 mmol/L) to minimize surgical complications, as recommended by the most recent guidelines 1. To achieve this, several key strategies can be employed:

• A preoperative risk assessment should be performed for people with diabetes who are at high risk for ischemic heart disease and those with autonomic neuropathy or renal failure 1.
• The A1C goal for elective surgeries should be <8% (<64.0 mmol/L) whenever possible 1.
• Metformin should be held on the day of surgery, and SGLT2 inhibitors should be discontinued 3–4 days before surgery 1.
• Other oral glucose-lowering agents should be held the morning of surgery or procedure, and insulin dose reductions may include NPH insulin to one-half of the dose or long-acting basal insulin analogs 1.
• 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 is crucial 1.
• Stricter perioperative glycemic goals are not advised, as they may not improve outcomes and are associated with increased hypoglycemia 1.
• 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 reactive, correction-only short- or rapid-acting insulin coverage alone with no basal insulin dosing 1.

From the FDA Drug Label

The intravenous administration of Humulin R U-100 was tested in 21 patients with type 1 diabetes The patients' usual doses of insulin were temporarily held, and blood glucose concentrations were maintained at a range of 200 – 260 mg/dL for one to three hours during a run-in phase of intravenous Humulin R U-100 followed by a 6-hour assessment phase.

The FDA drug label does not answer the question about diabetes perioperative risk assessment or recommendations for managing diabetes perioperatively in surgical patients. 2

From the Research

Perioperative Risk Assessment for Diabetes Patients

• The perioperative period is crucial for preventing acute complications in diabetic patients, such as hyperglycemia, hypoglycemia, and diabetic ketoacidosis 3.
• A thorough presurgical assessment is necessary to determine the optimal care plan, taking into account the patient's usual home diabetes regimen, level of diabetes control, surgery type, and duration of surgery 3.
• Hyperglycemia can have detrimental effects on postoperative outcomes, including increased risk of infection, poor wound healing, and mortality 4.

Recommendations for Managing Diabetes Perioperatively

• Avoidance of hypoglycemia while striving for adequate glucose control is recommended 4.
• Careful preoperative evaluation, clear patient instructions, frequent blood glucose monitoring, and effective strategies for insulin initiation and titration are essential for managing diabetes perioperatively 4.
• Pre-existing cardiac disease, diabetic end-organ disease, and peripheral vascular disease can predict postoperative complications in diabetic patients 5.

Medication Management

• Metformin is a commonly used antidiabetic medication that can be effective in lowering blood glucose levels without increasing the risk of hypoglycemia 6.
• Newer agents, such as sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists, may be favored as first-line therapy for patients with type 2 diabetes who require cardio-renal protection 6.
• Imeglimin, a new oral anti-diabetic drug, has been shown to enhance insulin secretion and incretin secretion, making it a potential therapeutic option for patients with diabetes 7.