Can fructosamine be used instead of Hemoglobin A1c (HbA1c) for preoperative clearance in patients with diabetes or glucose metabolism disorders?

Fructosamine for Preoperative Clearance: Current Evidence and Recommendations

Current perioperative guidelines recommend HbA1c testing for preoperative glycemic assessment, not fructosamine, though emerging research suggests fructosamine may be a superior predictor of surgical complications. 1

Guideline-Based Standard of Care

The established approach for preoperative glycemic assessment relies on HbA1c:

• Preoperative HbA1c testing is reasonable if not performed within the preceding 3 months for patients with or at risk for diabetes undergoing elective noncardiac surgery 1
• The target HbA1c for elective surgeries should be <8% whenever possible to reduce surgical risk, mortality, infection, and length of stay 1
• HbA1c measurement helps distinguish between undiagnosed diabetes and stress hyperglycemia in the perioperative period 1

Emerging Evidence for Fructosamine

Despite guideline recommendations favoring HbA1c, recent high-quality research demonstrates fructosamine's potential advantages:

Superior Predictive Value for Surgical Complications

• In a 2019 prospective multicenter study of 1,119 TKA patients, fructosamine >293 µmol/L was associated with 11.2 times higher risk of prosthetic joint infection, while HbA1c thresholds (including 7% and 7.5%) failed to show significant association with complications 2
• A 2024 retrospective study of 305 foot and ankle surgery patients found preoperative fructosamine significantly higher in those with 90-day complications (269.2 vs 247.2 µmol/L, p=0.029), and fructosamine was non-inferior to HbA1c in predicting postoperative complications 3

Clinical Advantages Over HbA1c

• Fructosamine reflects glycemic control over 2-3 weeks (albumin half-life) versus 8-12 weeks for HbA1c, making it more responsive to recent treatment changes 4, 5
• Fructosamine is unaffected by red blood cell disorders (hemolytic anemia, sickle cell disease, chronic transfusion therapy) that render HbA1c unreliable 4, 5
• The measurement is less expensive and can be automated on conventional laboratory instruments 4

Critical Gap Between Guidelines and Evidence

No current perioperative guidelines from major societies (ACC/AHA, ADA, French Society of Anaesthesia) recommend fructosamine for preoperative assessment, despite Level I evidence showing superior predictive value for surgical complications. 1, 2

This represents a significant disconnect where:

• Guidelines continue to recommend HbA1c based on historical precedent 1
• The highest quality prospective evidence demonstrates fructosamine's superiority in predicting the outcomes that matter most: infection, readmission, reoperation, and mortality 2

Practical Approach for Preoperative Assessment

Given the evidence-practice gap, consider the following algorithm:

When to Use Fructosamine Instead of (or in Addition to) HbA1c:

• Patients with red blood cell disorders (hemolytic anemia, sickle cell disease, recent transfusions) where HbA1c is unreliable 4, 5
• High-risk orthopedic procedures (total joint arthroplasty, foot/ankle surgery) where the evidence for fructosamine is strongest 3, 2
• Patients with recent changes in glycemic control where 2-3 week assessment window is more clinically relevant than 8-12 weeks 4, 5
• Discrepancies between glucose measurements and HbA1c values suggesting HbA1c may not accurately reflect glycemic control 5

Risk Stratification Thresholds:

• Fructosamine >293 µmol/L indicates markedly increased risk and should prompt consideration of delaying elective surgery for glycemic optimization 2
• For comparison, the traditional HbA1c threshold of >8% warrants referral to endocrinology and delay of elective surgery 1

Important Caveats

• Fructosamine measurement is not yet standardized across all laboratories, though glycated albumin (a related marker) has better standardization than fructosamine 4
• The evidence base for fructosamine is strongest in orthopedic surgery; extrapolation to other surgical specialties requires clinical judgment 3, 2
• Current institutional protocols and insurance coverage may not support routine fructosamine testing, requiring individual advocacy for its use 1

Common Pitfalls to Avoid

• Do not assume HbA1c is always reliable—it can be falsely low in hemolytic conditions, leading to underestimation of diabetes severity and delayed treatment 5
• Do not ignore elevated fructosamine values even when HbA1c appears acceptable, as fructosamine better predicts actual surgical complications 2
• Do not use fructosamine in patients with hypoalbuminemia or nephrotic syndrome, as these conditions affect albumin turnover and invalidate fructosamine measurements 4