What are the guidelines for managing oral hypoglycemic agents (OHAs) prior to surgery?

From the Guidelines

Oral hypoglycemic agents (OHAs) should be managed according to the latest guidelines, which recommend holding metformin on the day of surgery, discontinuing SGLT2 inhibitors 3-4 days before surgery, and holding other oral glucose-lowering agents the morning of surgery. When managing OHAs prior to surgery, it is essential to consider the individual's specific medication regimen and the type of surgery they will be undergoing.

• Metformin should be held on the day of surgery, as recommended by the latest guidelines 1.
• SGLT2 inhibitors should be discontinued 3-4 days before surgery to prevent potential complications, such as euglycemic diabetic ketoacidosis 1.
• Other oral glucose-lowering agents, such as sulfonylureas and DPP-4 inhibitors, should be held the morning of surgery to minimize the risk of hypoglycemia during the fasting period 1.
• The blood glucose goal in the perioperative period should be 100-180 mg/dL (5.6-10.0 mmol/L), and blood glucose should be monitored at least every 2-4 hours while the individual is taking nothing by mouth 1.
• Temporary insulin therapy may be required for patients undergoing major surgery or with poorly controlled diabetes, with a basal-bolus regimen being the preferred approach for achieving perioperative blood glucose goals with a lower risk for hypoglycemia 1. The A1C goal for elective surgeries should be <8% (<63.9 mmol/L) whenever possible, and stricter perioperative glycemic goals are not advised, as they may not improve outcomes and are associated with more hypoglycemia 1.

From the FDA Drug Label

When a patient stabilized on any diabetic regimen is exposed to stress such as fever, trauma, infection, or surgery, a loss of control may occur. At such times, it may be necessary to discontinue glyburide tablets and administer insulin 2 Loss of control of blood glucose: When a patient stabilized on any diabetic regimen is exposed to stress such as fever, trauma, infection, or surgery, a loss of control may occur. At such times, it may be necessary to discontinue glyburide tablets and administer insulin 2

The guidelines for managing oral hypoglycemic agents (OHAs) prior to surgery are not explicitly stated in the provided drug labels. However, it is mentioned that loss of control of blood glucose may occur when a patient is exposed to stress such as surgery, and it may be necessary to discontinue OHAs and administer insulin.

• The decision to discontinue OHAs and administer insulin should be based on individual patient response and clinical judgment.
• Close monitoring of the patient's blood glucose levels is necessary during the transition period.
• It is also important to note that the risk of hypoglycemia may be increased during the transition period, and patients should be instructed to contact their prescriber immediately if they experience any symptoms of hypoglycemia. 2, 2

From the Research

Guidelines for Managing Oral Hypoglycemic Agents (OHAs) Prior to Surgery

• The management of OHAs prior to surgery is crucial to maintain optimal blood glucose levels and prevent complications 3, 4.
• A randomized controlled trial found that continuing OHAs preoperatively resulted in lower perioperative blood glucose levels compared to withholding them 3.
• The American Diabetes Association recommends screening for diabetes and hyperglycemia in the preoperative period, and using oral hypoglycemics and insulin as needed to maintain blood glucose levels below 180 mg/dL 4.
• However, the risk of hypoglycemia should also be considered, particularly in patients with low normal fasting preoperative blood glucose levels 5.
• A retrospective study found that patients with low normal preoperative blood glucose levels were at higher risk of developing perioperative hypoglycemia compared to those with hyperglycemia treated with insulin 5.
• The choice of oral hypoglycemic agent should be individualized based on the patient's medical history and medication regimen, and certain agents may be contraindicated in certain patients 6.
• Continuous glucose monitoring can help identify patients at risk of hypo- and hyperglycemia in the perioperative period, and may be useful in guiding glucose management 7.

Key Considerations

• Blood glucose levels should be monitored closely in the preoperative period to identify patients at risk of hypo- or hyperglycemia 4, 5, 7.
• The use of oral hypoglycemics and insulin should be individualized based on the patient's medical history and medication regimen 3, 4, 6.
• Patients with low normal preoperative blood glucose levels may be at higher risk of developing perioperative hypoglycemia 5.
• Continuous glucose monitoring may be useful in guiding glucose management in the perioperative period 7.