Ambulatory anesthesia: optimal perioperative management of the diabetic patient

Figures & data

Table 1 Perioperative management of oral antidiabetics

Drug class	Primary mechanism of action	Main perioperative risks	Recommendation
Biguanides (metformin)	Reduces hepatic gluconeogenesis, increases insulin sensitivity (T½: 6–18 h)	None*	Continue. May be withheld in case of renal failure or when using contrast agents
Sulfonylureas (tolbutamide, gliclazide, glimepiride)	Stimulates insulin release (T½: 2–10 h)	Hypoglycemia, interference with cardiac ischemic preconditioning	Withhold on the day of surgery
Meglitinides (repaglinide)	Stimulates insulin release (T½: 1 h)	Hypoglycemia	Withhold on the day of surgery
Thiazolidinediones (pioglitazone)	Modulates carbohydrate and fatty acid metabolism, reduces insulin resistance and hepatic gluconeogenesis (T½: 3–8 h)	Fluid retention	Withhold 24–48 h before surgery
Alpha glucosidase inhibitors (acarbose, miglitol)	Reduces intestinal glucose absorption	None	Withhold during fasting
SGLT-2 inhibitors (dapagliflozine)	Reduces glucose reabsorption in kidney	Reduced plasma volume, DKA	Withhold on the day of surgery
DPP-4 inhibitors (sitagliptin)	Stimulates insulin release and inhibits glucagon release (glucose-dependent)	Unlikely	Continue
GLP-1 agonists (exenatide, liraglutide)	Stimulates insulin release and inhibits glucagon release (glucose-dependent)	Unlikely	Continue

Note: *Does not apply to withdrawn biguanides (eg, phenformin, buformin).

Abbreviations: DKA, diabetic ketoacidosis; h, hours; SGLT-2, sodium-glucose cotransporter 2; DPP-4, dipeptidyl peptidase-4; GLP-1, glucagon-like peptide-1; T½, context-sensitive half-time.

Table 2 Time to onset, peak effect, and total duration of various insulin types

Insulin type	Onset	Peak effect	Total duration
Short- and rapid-acting insulin
Regular insulin	30–60 min	2–4 hours	6–8 hours
Lispro, aspart, and glulisine	5–15 min	30–90 min	4–6 hours
Intermediate acting or premixed insulin
NPH	2–4 hours	4–10 hours	10–16 hours
NPH/regular (70/30, 50/50)	30–90 min	Dual	10–16 hours
Long-acting insulin
Lantus^© and Detemir	2–4 hours	None	20–24 hours
Toujeo^© and Degludec	30–90 min	None	36–42 hours

Abbreviations: min, minutes; NPH, neutral protamine Hagedorn.

Table 3 Management of insulin regimens

Insulin regimen	Day before surgery	Day of surgery	Comments
Long-acting insulin (long-acting only, basal component of basal-bolus regimen)	No change	No change	75% of evening or morning dose in case of Degludec/Toujeo^©, nocturnal or morning hypoglycemia
Intermediate-acting or premixed insulin	No change	50–75% of morning dose	In case of premixed insulin, use the intermediate-acting component only
Short- and rapid-acting insulin	No change	Withhold until resumption of usual intake
Insulin pump (basal-bolus)	No change	Maintain basal rate (sleep rate)^a until resumption of usual intake	Give correctional insulin boluses via separate injection

Note:

a Safety measures mentioned in this article should be taken into account when using insulin pumps during surgery.