You’ll get questions about how to manage diabetes meds around surgery...partly due to rising use of SGLT2 inhibitors and GLP-1 agonists.
Share guidance with patients and providers about timing of specific diabetes meds around planned surgery to avoid peri-op complications.
Avoid risks from newer diabetes medications. Hold an SGLT2i (canagliflozin, etc) for at least 3 days before surgery. Fasting with an SGLT2i may cause ketoacidosis despite normal glucoses.
Counsel patients to report any new ketosis symptoms...such as nausea, fruity breath, or fatigue...around surgery.
Advise restarting the SGLT2i after all procedures are complete and the patient is stable with adequate oral intake. Ensure other risks for ketoacidosis (infection, etc) are resolved as well.
Generally recommend holding daily GLP-1s (liraglutide, etc) on the procedure day...or hold weekly versions (semaglutide, etc) 1 week prior. These meds can delay gastric emptying...increasing concerns about peri-op aspiration and symptoms mistaken for ileus.
Be aware, a GLP-1 agonist might be continued in select cases...since gastric emptying improves over time. For example, patients report less nausea and diarrhea after the first month on a GLP-1. Concerned providers may take more aspiration precautions when a GLP-1 wasn’t held pre-op.
Emphasize restarting a GLP-1 post-op once nausea and vomiting have resolved and patients are tolerating po. Follow guidance for missed doses. For example, consider re-titrating a patient’s weekly GLP-1 if 2 or more doses are missed...especially if they had GI side effects.
Apply these same approaches when an SGLT2i or GLP-1 agonist is used for other indications...such as CV risk reduction or weight loss.
Avoid peri-op hypoglycemia. Recommend pausing any fast-acting insulins (lispro, etc)...along with sulfonylureas (glipizide, etc)...while NPO to avoid low glucose.
Similarly, advise omitting the morning dose of premix insulin (NPH/regular, etc) pre-op for fasting glucose less than 200 mg/dL. Recommend just NPH at 50% of the scheduled dose instead in these cases.
Generally continue long-acting insulins...but reduce pre-op doses. For example, patients can decrease their pre-op dose of insulin glargine by at least 20% the night before or morning of surgery.
If post-op food intake isn’t adequate, consider reducing insulin doses by 20% to 25%. This can maintain glucose until eating improves.
Review our chart, Perioperative Management of Diabetes, for more details on timing other medications...such as metformin...around surgery.
And use our chart, Perioperative Management of Chronic Medications, to answer questions about ACEIs and ARBs, statins, and more.
- Pfeifer KJ, Selzer A, Mendez CE, et al. Preoperative Management of Endocrine, Hormonal, and Urologic Medications: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement. Mayo Clin Proc. 2021 Jun;96(6):1655-1669.
- American Diabetes Association Professional Practice Committee. 16. Diabetes Care in the Hospital: Standards of Care in Diabetes-2024. Diabetes Care. 2024 Jan 1;47(Suppl 1):S295-S306.
- Gorgojo-Martínez JJ, Mezquita-Raya P, Carretero-Gómez J, et al. Clinical Recommendations to Manage Gastrointestinal Adverse Events in Patients Treated with Glp-1 Receptor Agonists: A Multidisciplinary Expert Consensus. J Clin Med. 2022 Dec 24;12(1):145.
- Joshi GP, Abdelmalak BB, Weigel WA, et al. American Society of Anesthesiologists Consensus-Based Guidance on Preoperative Management of Patients (Adults and Children) on Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists. June 29, 2023. https://www.asahq.org/about-asa/newsroom/news-releases/2023/06/american-society-of-anesthesiologists-consensus-based-guidance-on-preoperative (Accessed Sep 12, 2024).