Glycemia management in patients on oral agents
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In these powerpoints I describe how to control glycemia in the perioperative period in patient with diabetes not taking insulin. Please download these slides and view them in PowerPoint so you can view the annotations describing each slide.
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Glycemia management in patients on oral agents
- 1. Perioperative Diabetes Management: Oral Agents and Noninsulin Injectables Terry Shaneyfelt, MD, MPH Assoc. Professor, UAB Department of Medicine The information contained in these slides is for educational purposes only and not meant to guide clinical care. Please refer to package inserts and guidelines for prescribing information.
- 2. There is little evidence on the optimal perioperative management of diabetes
- 3. Goals of glycemic control 1. Avoid hypoglycemia 2. Prevent ketoacidosis and hyperosmolar states 3. Maintain fluid and electrolyte balance 4. Avoid marked hyperglycemia • Optimal perioperative glycemic targets unclear: • ADA: fasting <140 mg/dl for general hospitalized patients (random < 180 mg/dl) • CDA: Perioperative glycemic levels should be maintained between 90-180 mg/dl
- 4. Perioperative glycemia management • No consensus on optimal management strategy to maintain target glucose levels • Surgery should be scheduled as early as possible in the morning to minimize NPO time
- 5. Diet controlled type 2 diabetes • Blood glucose monitoring: • Preop and postop • Long surgeries: Q1-2 hours • Most do not require any therapy • Short or rapid-acting insulin SQ Q6 hrs to correct glucose over desired target
- 6. Type 2 diabetes controlled with oral hypoglycemic agents or noninsulin injectables • Blood glucose monitoring:Q2 hrs • Continue usual meds until morning of surgery • Morning of surgery: hold meds • Hyperglycemia: • Short procedures, good control: Usually wont need correction insulin • Short procedures: short or rapid-acting insulin SQ Q6 hrs to correct glucose over desired target • Long, complex procedures: IV insulin • Restart usual meds postop when eating
- 7. Metformin • “Metformin therapy should be temporarily suspended for any surgical procedure (except minor procedures not associated with restricted intake of food and fluids) and should not be restarted until the patient's oral intake has resumed and renal function has been evaluated as normal.” • Package insert • Data is inconclusive
- 8. Knowledge Check • You are asked to see a 67 yo M with type 2 DM in the CCU 1 day post CABG. He takes glyburide and metformin as an outpt. Last A1C 8.5%. OR blood glucose ranged from 173-310 mg/dl. Glucose 1 hour ago was 188 mg/dl. What do you recommend? A. Glucose is < 200 mg/dl and is improving. You recommend sliding scale aspart insulin Q4-6 hrs if glucose over 200 mg/dl. Restart oral agents when tolerating po. B. Continuous insulin infusion with target glucose at 100-140 mg/dl C. Continuous insulin infusion with target glucose at 140-180 mg/dl D. Since the patient’s diabetes is uncontrolled before admission you conclude the patient will need basal insulin at discharge. You decide to initiate it now to facilitate determining the patient’s home dose. You order glargine insulin 10U at night.
Editor's Notes
- These PowerPoints will review glycemia management in diabetic patients on oral hypoglycemic agents and noninsulin injectables during the perioperative period.
- There is little evidence to guide the optimal management of diabetes in the perioperative period. Some is extrapolated from studies of the management of hospitalized patients with diabetes. Much of it is opinion.
- There are 4 broad goals of glycemic control in the perioperative period: avoid hypoglycemia, avoid marked hyperglycemia, avoid ketoacidosis, and maintain fluid and electrolyte balance. The optimal perioperative glycemic targets are unclear and based on opinion (Canadian guidelines) or based upon goals for hospitalized patients in general (ADA).
- Opinions vary as how to best maintain blood glucose in the target range. Surgery should be scheduled in early morning to minimize NPO time and to minimize disruption of the management routine.
- Most diet controlled type 2 diabetics need no perioperative therapy. If blood glucose rises above the desired target short (ie regular) or rapid acting insulin (eg lispro, aspart) can be administered every 6 hours. Blood glucose should be checked Q1-2 hours on insulin or during long surgeries. Otherwise, blood glucose can be checked preop and then shortly after surgery.
- Type 2 diabetics on oral agents or noninsulin injectables should have their blood glucose monitored every 2 hours. These patients should continue their usual agent until the morning of surgery when they should hold their usual medications. Patients with good control (A1C <7) or undergoing short procedures usually will need no correction insulin. Patients who develop hyperglycemia undergoing short procedures can be given short or rapid acting insulin every 6 hours until eating and home medications are resumed. Longer, complex procedures usually require IV insulin. Home medications are restarted when eating postoperatively.
- At worst metformin rarely causes lactic acidosis. In many of these cases patients had other comorbidities that likely led to the lactic acidosis. Nonetheless, the package insert recommends stopping metformin prior to surgery and restarting it only after assuring normal renal function. Some have suggested stopping it 48 hrs prior to surgery. There are actually cardiac surgery studies that show its use to be beneficial on cardiac outcomes. I think at best the data is inconclusive. The conservative thing to do it to hold it 1-2 days prior to surgery and restart it after surgery assuming there is no more risk of hypoperfusion and that renal function is normal.
- A is incorrect because goal blood sugar is not less than 200 mg/dl. B is incorrect because the target glucose is 140-180 mg/dl according to the ADA. C is correct because the target is 140-180 mg/dl and the patient underwent a complex procedure that likely would have required insulin. D is incorrect. While all this is true starting a home regimen in the ICU would not be appropriate. It is expected that insulin requirements would change widely and variable. It would be better to start a home insulin regimen once out of the ICU and eating regularly.