What are the Lantus (insulin glargine) dosing recommendations for patients undergoing surgery?

Lantus (Insulin Glargine) Recommendations for Perioperative Management

For patients undergoing surgery, Lantus (insulin glargine) should be reduced to 75-80% of the usual dose the evening before surgery to minimize the risk of perioperative hypoglycemia while maintaining adequate glycemic control. 1

Preoperative Lantus Management

• For minor or ambulatory procedures where the patient will resume eating soon after surgery:

  • Administer 75-80% of the usual Lantus dose the evening before surgery 1
  • Hold oral antidiabetic medications on the morning of surgery 1
  • Monitor blood glucose every 2-4 hours while NPO 1

• For major surgery or procedures requiring prolonged fasting:

  • For patients with well-controlled diabetes (HbA1c <8%):

    • Administer 75-80% of usual Lantus dose the evening before surgery 1
    • Consider transitioning to IV insulin for major surgeries 1

  • For patients with poorly controlled diabetes (HbA1c >9%):

    • Consider hospital admission for glycemic optimization 1
    • Transition to basal-bolus insulin regimen or IV insulin infusion 1

Intraoperative Management

• For minor procedures:

  • Continue with reduced Lantus dosing (75-80% of usual dose) 1
  • Monitor blood glucose every 2-4 hours 1

• For major procedures:

  • Consider discontinuing Lantus and transitioning to IV insulin infusion, especially for:
    • Abdominal surgeries 1
    • Procedures causing significant ileus 1
    • Patients who will be NPO for more than one meal 1
    • Emergency surgeries 1

• When transitioning from Lantus to IV insulin:

  • Start IV insulin at least 30 minutes before removing subcutaneous insulin effect 1
  • Initial IV insulin rate can be calculated based on the patient's usual hourly basal rate 1

Postoperative Management

• For patients resuming oral intake quickly:

  • Resume previous Lantus treatment at the same doses after 48 hours if renal function is adequate (clearance >30 mL/min for oral agents, >60 mL/min for metformin) 1

• For patients transitioning from IV insulin back to Lantus:

  • Connect insulin pump or administer Lantus at least 2 hours before stopping IV insulin to prevent rebound hyperglycemia 1
  • For patients previously on insulin pump therapy who need to transition to Lantus:
    • Calculate the 24-hour basal dose from the pump 1
    • Administer this as Lantus in two divided doses 12 hours apart 1

• For patients with HbA1c between 8-9%:

  • Resume oral antidiabetics at the same doses if no contraindications 1
  • Continue Lantus and adjust dosing based on blood glucose monitoring 1

Special Considerations

• A dosing adjustment strategy based on usual glycemic control may better prevent severe preoperative hyperglycemia in patients on basal-bolus regimens 2

• Target perioperative blood glucose range should be 100-180 mg/dL (5.6-10.0 mmol/L) 1

• Lantus is effective in hospitalized and postsurgical patients due to its lack of pronounced insulin peaks and long duration of action 3

• Morning administration of Lantus is as effective as bedtime administration, offering flexibility in perioperative scheduling 4

• The primary advantage of Lantus over NPH insulin is lower frequency of hypoglycemic reactions, providing improved safety in the perioperative setting 3, 5

• For patients on insulin pumps requiring surgery, the 24-hour basal insulin dose can be replaced with equivalent Lantus doses divided into two injections 12 hours apart 1

• Avoid tight glycemic targets (<80 mg/dL) in the perioperative period as they do not improve outcomes and increase hypoglycemia risk 1