Perioperative Insulin Management for EGD and Colonoscopy
Recommended Approach
On the morning of the procedure, administer 70-80% of the patient's usual Lantus dose (14-16 units) and completely discontinue the sliding scale insulin regimen, replacing it with a structured basal-bolus approach postoperatively. 1
Day of Procedure Protocol
Morning Insulin Dosing
- Give 14-16 units of Lantus (70-80% of usual 20 units) on the morning of the procedure 1
- This 20-25% reduction prevents hypoglycemia during the fasting period while maintaining basal coverage 1
- Administer at the patient's usual time if possible 1
Monitoring Requirements
- Check fasting blood glucose before the procedure 1
- Monitor glucose every 2-4 hours during the perioperative period 2
- Have glucose tablets or IV dextrose immediately available for hypoglycemia treatment 2
Critical Problems with Current Regimen
Sliding scale insulin as monotherapy is explicitly condemned by all major diabetes guidelines and should be immediately discontinued. 1 The current regimen of Lantus plus sliding scale represents inadequate diabetes management for several reasons:
- Sliding scale insulin treats hyperglycemia reactively after it occurs rather than preventing it 1
- This approach leads to dangerous glucose fluctuations and poor glycemic control 1
- Scheduled basal-bolus regimens are superior to sliding scale monotherapy 1
Post-Procedure Insulin Regimen
Resume Full Basal Insulin
- Return to Lantus 20 units once daily after the patient resumes oral intake 1
- Continue at the same time each day for consistency 1
Add Structured Prandial Coverage
The patient requires prandial insulin in addition to basal insulin, not sliding scale monotherapy. 1 Based on the inadequacy of the current regimen:
- Start with 4 units of rapid-acting insulin (lispro, aspart, or glulisine) before the largest meal 1
- Alternatively, use 10% of the basal dose (2 units) before each meal 1
- Titrate prandial doses by 1-2 units every 3 days based on 2-hour postprandial glucose readings 1
Correction Insulin (Not Sliding Scale)
- Use correction doses as an adjunct to scheduled insulin, not as monotherapy 1
- Calculate insulin sensitivity factor: 1500 ÷ total daily dose 1
- Apply correction doses only when blood glucose exceeds target before meals 1
Foundation Therapy Considerations
Continue Metformin
- Metformin should be continued unless contraindicated, even when intensifying insulin therapy 1
- Metformin may be temporarily held 24-48 hours before the procedure if there are concerns about renal function or contrast administration 2
- Resume metformin after the procedure once oral intake is established and renal function is stable 2
Hypoglycemia Prevention and Treatment
Recognition and Treatment Protocol
- Treat hypoglycemia at blood glucose ≤70 mg/dL with 15 grams of fast-acting carbohydrate 1
- Recheck glucose in 15 minutes and repeat treatment if needed 2
- Staff should have glucagon available for severe hypoglycemia 2
Risk Mitigation
- The reduced Lantus dose (70-80%) on procedure day specifically addresses hypoglycemia risk during fasting 1
- If hypoglycemia occurs, reduce the next Lantus dose by 10-20% 1
Common Pitfalls to Avoid
Do Not Continue Sliding Scale Monotherapy
- Sliding scale as sole treatment is ineffective and dangerous 1
- Scheduled basal insulin with correction doses as adjunct only is superior 1
Do Not Delay Prandial Insulin Addition
- The current regimen suggests inadequate glycemic control requiring both basal and prandial coverage 1
- Continuing to rely on sliding scale without structured prandial insulin leads to suboptimal control 1
Do Not Omit All Insulin on Procedure Day
- Complete insulin omission risks hyperglycemia and metabolic decompensation 1
- Reduced basal insulin (70-80%) maintains coverage while preventing hypoglycemia 1
Monitoring and Follow-Up
Immediate Post-Procedure Period
- Monitor glucose every 2-4 hours until stable oral intake is established 2
- Adjust insulin doses by 10-20% if hypoglycemia occurs 1