What are the Canadian guidelines for discharge of a patient with a history of diabetes, possibly on Invokana (canagliflozin), after surgery?

Canadian Guidelines for Patient Discharge After Surgery in Diabetic Patients

Immediate Post-Operative Insulin Management

For patients with diabetes who underwent surgery, Canadian standards emphasize structured discharge planning that begins at admission and addresses glycemic control, medication reconciliation, and appropriate follow-up timing based on diabetes type and control. 1

Type-Specific Insulin Resumption

Type 1 Diabetes:

• Resume basal insulin immediately when discontinuing IV insulin to prevent life-threatening ketoacidosis 2
• Continue the basal-bolus regimen at the same doses used during hospitalization 3
• If the last basal insulin injection was >24 hours ago, administer it immediately upon stopping the insulin infusion 2
• For insulin pump users, restart the pump as soon as IV insulin is discontinued 2

Type 2 Diabetes on Insulin:

• Resume previous insulin treatment at the doses used during hospitalization 3
• If HbA1c <8%, consider transitioning to oral agents after 48 hours if renal function permits (creatinine clearance >60 mL/min for metformin, >30 mL/min for other oral agents) 4
• If HbA1c 8-9%, continue basal insulin at discharge with dose titration protocol and arrange diabetologist consultation 4
• If HbA1c >9% or blood glucose >11 mmol/L (>200 mg/dL), maintain full basal-bolus insulin regimen—do not transition to oral agents alone 4

Type 2 Diabetes Previously on Oral Agents Only:

• If HbA1c <8%, resume previous oral antidiabetic agents at the same doses after 48 hours, provided renal clearance is adequate 4
• Continue capillary blood glucose monitoring before each meal to guide any remaining bolus insulin dosing 4

Critical Discharge Planning Components

Medication Reconciliation (Mandatory)

The Agency for Healthcare Research and Quality requires at minimum: 3

• Cross-check all medications to ensure no chronic medications were stopped inadvertently 3
• Verify safety of all new prescriptions 3
• Fill prescriptions for new or changed medications and review with patient and family at or before discharge 3
• Provide clear written instructions including specific medication names, doses, and timing 4

Special Considerations for Canagliflozin (Invokana)

If the patient was on canagliflozin pre-operatively, withhold it for at least 3 days prior to surgery or procedures associated with prolonged fasting 5

Critical safety concerns when resuming canagliflozin post-discharge:

• Do not resume canagliflozin until the patient has fully recovered, is eating normally, and has stable fluid status 5
• Canagliflozin carries risk of diabetic ketoacidosis even with normal or mildly elevated blood glucose levels 5, 6, 7
• Assess for ketoacidosis regardless of presenting blood glucose levels before resuming 5
• Consider ketone monitoring in patients at risk for ketoacidosis 5
• Monitor for signs of volume depletion, urinary tract infections, and genital mycotic infections 5

Structured Follow-Up Schedule

Canadian standards and American Diabetes Association guidelines recommend: 3, 1

For HbA1c <8%:

• Follow-up with primary care provider within 1 month of discharge 3, 4

For HbA1c 8-9%:

• Arrange consultation with diabetologist 4
• Earlier appointment (1-2 weeks) if glycemic medications were changed or glucose control not optimal at discharge 3

For HbA1c >9% or unstable blood glucose levels (>11 mmol/L or 200 mg/dL):

• Request diabetologist advice before discharge for possible hospitalization in specialized service 3, 4
• Frequent contact may be needed to avoid hyperglycemia and hypoglycemia 3

Patient Education Requirements at Discharge

Essential education components include: 3, 4

• Blood glucose monitoring schedule with pre-prandial testing before each meal 4
• Hypoglycemia recognition and treatment plan (15 grams of fast-acting carbohydrate for blood glucose <3.3 mmol/L or 60 mg/dL) 4
• Proper insulin injection technique and site rotation 3
• "Sick day" management rules 3
• Insulin storage and handling 3
• When to contact healthcare provider urgently 3

Discharge Blood Glucose Targets

Target ranges for discharge planning: 3, 1

• Fasting plasma glucose: 80-130 mg/dL (4.4-7.2 mmol/L) 3
• Pre-meal glucose: 90-150 mg/dL (5.0-8.3 mmol/L) 3
• Postprandial glucose: <180 mg/dL (10.0 mmol/L) 3

Common Pitfalls to Avoid

Critical errors in discharge planning: 3, 4, 2

• Never discontinue basal insulin in Type 1 diabetes patients—this creates immediate ketoacidosis risk 2
• Do not resume canagliflozin immediately post-operatively without ensuring stable oral intake and fluid status 5
• Do not delay follow-up appointments for patients with HbA1c >9%—arrange diabetologist consultation before discharge 4
• Never discharge patients on sliding scale insulin alone without scheduled basal insulin 3
• Do not stop metformin when resuming insulin unless contraindicated (creatinine clearance <60 mL/min) 2

Documentation Requirements

Discharge summaries must include: 3

• Cause of hyperglycemia or plan for determining the cause 3
• Related complications and comorbidities 3
• Recommended treatments with specific doses and timing 3
• Clear communication with outpatient providers to facilitate safe transitions 3