Can a patient with uncontrolled diabetes mellitus (indicated by a Hemoglobin A1c (HbA1c) level over 10) undergo a tonsillectomy (removal of the tonsils)?

From the Guidelines

A patient with uncontrolled diabetes mellitus, indicated by a Hemoglobin A1c (HbA1c) level over 10, should not undergo a tonsillectomy without first improving their blood sugar control, as uncontrolled diabetes can lead to increased risks of perioperative complications, including infection and mortality, as seen in studies such as 1.

Risks Associated with Uncontrolled Diabetes

The risks associated with uncontrolled diabetes in the context of surgery are well-documented:

• Perioperative hyperglycemia is an independent risk factor for postoperative morbidity and mortality, as highlighted in 1.
• Uncontrolled perioperative hyperglycemia is associated with a higher risk of postoperative complications, including infections, as noted in 1.
• The prognosis of hyperglycemia appears to be different depending on whether it is stress hyperglycemia or chronic imbalance in a patient with pre-existing diabetes, suggesting that patients with known diabetes may have a different risk profile compared to those without, as discussed in 1.

Recommendations for Diabetes Management Before Surgery

Given the risks, it is crucial to manage the patient's diabetes before proceeding with elective surgery like a tonsillectomy. Recommendations from the most recent guidelines, such as 1, suggest:

• The A1C goal for elective surgeries should be <8% (<64.0 mmol/L) whenever possible.
• Blood glucose goals in the perioperative period should be 100–180 mg/dL (5.6–10.0 mmol/L) within 4 hours of surgery.
• Adjustments to diabetes medications, such as holding metformin on the day of surgery and discontinuing SGLT2 inhibitors 3–4 days before surgery, may be necessary.
• Insulin dose adjustments, including reducing NPH insulin to one-half of the dose or long-acting basal insulin analogs, should be considered.

Improving Blood Sugar Control

To improve blood sugar control, patients should work with their healthcare provider to adjust their medication regimen, dietary habits, and physical activity levels. This may include:

• Starting or adjusting medications like metformin, GLP-1 agonists, or insulin therapy, as appropriate for the individual's condition.
• Implementing dietary changes to better manage blood glucose levels.
• Increasing physical activity, under the guidance of a healthcare provider, to help improve insulin sensitivity and glucose control.

Conclusion on Tonsillectomy

Until the patient's diabetes is better controlled, with an HbA1c closer to the target range (typically below 7%), elective surgeries like a tonsillectomy should be postponed to minimize the risks associated with uncontrolled diabetes and ensure the best possible outcomes for the patient, as supported by the guidelines and evidence from studies like 1.

From the Research

Tonsillectomy in Patients with Uncontrolled Diabetes Mellitus

• The decision to undergo a tonsillectomy (removal of the tonsils) in patients with uncontrolled diabetes mellitus, indicated by a Hemoglobin A1c (HbA1c) level over 10, requires careful consideration of the potential risks and benefits.
• According to a systematic review published in the European journal of anaesthesiology 2, preoperative testing for blood glucose and HbA1c may not be necessary for otherwise healthy adult patients undergoing elective noncardiac surgery, unless there are clinical signs arousing suspicion.
• However, another study published in the Journal of diabetes and its complications 3 suggests that patients with diabetes mellitus are at a high risk of postoperative complications, including infections and impaired wound healing, and that improving glycemic control prior to surgery may be beneficial.

Risks and Complications

• A study published in the journal JAMA 4 found that patients with type 2 diabetes mellitus who had poor glycemic control, as indicated by elevated HbA1c levels, were at a higher risk of complications, including cardiovascular events and mortality.
• However, another study published in The journal of hand surgery Asian-Pacific volume 5 found no significant difference in the 30-day complication rates between diabetic and non-diabetic patients undergoing elective hand surgery, and no increased risk of complications with increased HbA1c value.
• A systematic review published in Current pharmaceutical design 6 compared the safety and efficacy of sulfonylureas and dipeptidyl peptidase-4 inhibitors as second-line therapies in type 2 diabetes mellitus, and found that while sulfonylureas were more effective in lowering HbA1c, they were also associated with a higher risk of hypoglycemic events.

Considerations for Tonsillectomy

• Based on the available evidence, it appears that the decision to undergo a tonsillectomy in patients with uncontrolled diabetes mellitus should be made on a case-by-case basis, taking into account the individual patient's overall health and the potential risks and benefits of the procedure 2, 3, 5.
• Patients with uncontrolled diabetes mellitus may be at a higher risk of complications, including infections and impaired wound healing, and may require closer monitoring and management of their blood glucose levels perioperatively 3, 4.