What is the recommended insulin management for a diabetic patient taking insulin, including long-acting insulin (e.g. glargine or detemir), who is undergoing an Esophagogastroduodenoscopy (EGD) and colonoscopy, specifically regarding holding insulin doses the night before the procedure?

Insulin Management the Night Before EGD and Colonoscopy

For patients on long-acting basal insulin (glargine or detemir) undergoing EGD and colonoscopy, reduce the evening basal insulin dose by 25% the night before the procedure. 1, 2

Specific Dosing Recommendations

• Give 75% of the usual long-acting analog dose (glargine or detemir) the evening before the procedure 1, 2, 3
• This 25% reduction is more likely to achieve perioperative blood glucose goals (100-180 mg/dL) with significantly lower risk for hypoglycemia compared to usual dosing 1, 2
• Do NOT hold the basal insulin entirely the night before—this leads to hyperglycemia and worse perioperative outcomes 2, 3

Why This Matters

The 25% dose reduction is critical because 78% of hypoglycemic episodes in patients on basal insulin occur overnight when patients are NPO 2. The most common and dangerous error is failing to reduce the evening basal insulin dose, which significantly increases overnight hypoglycemia risk 2.

Morning of Procedure

• Hold all short-acting/rapid-acting insulin the morning of the procedure 1, 3
• Hold all oral diabetes medications the morning of the procedure 1, 3
• The basal insulin given the night before will provide coverage through the procedure 2, 3

Monitoring Requirements

• Monitor blood glucose at least every 2-4 hours while the patient is NPO 1, 2, 3
• More frequent monitoring overnight is recommended when hypoglycemia risk peaks 2
• Target blood glucose range: 100-180 mg/dL perioperatively 1, 3

Correction Insulin Protocol

• Use short- or rapid-acting insulin for correction doses as needed based on point-of-care glucose monitoring 1, 2, 3
• Administer correction insulin when glucose exceeds 180 mg/dL 2, 3
• Continue basal insulin coverage even while NPO 2, 3

Hypoglycemia Management

• Start D5 infusion if blood glucose falls below 70 mg/dL or is trending downward despite the reduced basal insulin dose 2
• D5 infusion is NOT routinely necessary for all NPO patients on basal insulin, but should be readily available 2

Common Pitfalls to Avoid

• Never discontinue basal insulin entirely while NPO—this is a critical error that leads to hyperglycemia 2, 3
• Never give the full usual dose the night before—this dramatically increases overnight hypoglycemia risk 1, 2
• Ensure the patient understands to take the reduced dose (75% of usual) the night before, not skip it entirely 2, 3