Managing Diabetes Meds Around Surgery

In this episode, TRC Healthcare editor, Stephen Small, PharmD, BCPS, BCPPS, BCCCP, CNSC, discusses the management of diabetes meds around surgery. 

This is an excerpt from our November 2024 Pharmacy Essential Updates continuing education webinar series.

The clinical resources mentioned during the podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights: 

• Article: Guide Peri-Op Management of Diabetes Medications 
• Chart: Perioperative Management of Diabetes 
• Chart: Perioperative Management of Chronic Medications in Noncardiac Surgery 

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Transcript

This transcript is automatically generated. 

00:00:04 Narrator

Welcome to Clinical Capsules, where we bring you the same evidence-based insights you trust from TRC Healthcare, now in podcast form. We’re thrilled to launch this new series as we celebrate 40 years of keeping healthcare professionals ahead of critical medication updates and guidelines.

00:00:23 Narrator

Every 2nd and 4th Tuesday, our expert editors from Pharmacist’s Letter, Prescriber Insights, and Pharmacy Technician’s Letter will break down the most impactful clinical developments - giving you clear, actionable takeaways in just minutes. 

00:00:38 Narrator

Today, you’ll hear an excerpt from our November 2024 Pharmacy Essential Updates continuing education webinar series. In this segment, Assistant Editor and Pharmacist Steven Small examines the management of diabetes meds around surgery.  

00:00:57 Narrator

With that, let's get started.

00:01:02 Stephen Small

Now it's time to talk about perioperative diabetes medication management or how to manage diabetes meds around planned surgeries.

00:01:13 Stephen Small

As our article discusses, you'll get questions about how to manage diabetes meds around surgery, partly due to rising use of SGLT 2 inhibitors and GLP 1 agonists.

00:01:25 Stephen Small

I was surprised to find out about one in five surgery patients actually have diabetes.

00:01:31 Stephen Small

They may be taking multiple meds that require holding for a certain length of time before an elective procedure.

00:01:37 Stephen Small

Patients may need your help explaining this timing.

00:01:41 Stephen Small

Forgetting to space or hold certain diabetes meds can lead to procedure delays or even patient harm. 

00:01:48 Stephen Small

And know that forgetting to restart a health Med post OP can also cause complications due to under treatment.

00:01:57 Stephen Small

We'll be talking about several meds today

00:02:02 Stephen Small

I'll first talk about SGLT 2 inhibitors such as empagliflozin and then GLP-1 agonists like liraglutide.

00:02:11 Stephen Small

Then I'll go over metformin and wrap things up by talking about insulins along with sulfonylureas like glipizide.

00:02:19 Stephen Small

Since the risks are similar.

00:02:22 Stephen Small

We'll talk about each med's risks when to hold them and when you should expect to restart them. Post Op to keep patients safe.

00:02:32 Stephen Small

Now let's use a case to start.

00:02:35 Stephen Small

We have Scott here and he's 56 years old.

00:02:38 Stephen Small

He comes up to the pharmacy counter asking about his canagliflozin an SGLT2 inhibitor and exenatide, a GLP1 agonist for his diabetes.

00:02:49 Stephen Small

He tells you he is a planned hip surgery coming up in two weeks.

00:02:54 Stephen Small

His surgeon told him he would need to hold these meds beforehand, but he doesn't recall the specific timing and he has trouble understanding his pre OP instructions.

00:03:06 Stephen Small

So what questions did you ask to determine your next steps?

00:03:13 Stephen Small

Let's first address Scott's SGLT 2 inhibitor.

00:03:17 Stephen Small

With these meds, we're worried about the risk of euglycemic diabetic ketoacidosis, or euglycemic, DKA for short.

00:03:28 Stephen Small

This is serious and life threatening.

00:03:31 Stephen Small

Know that euglycemia means normal glucose in typical DKA.

00:03:37 Stephen Small

Blood sugars are very high and uncontrolled, but in this case it's different.

00:03:42 Stephen Small

The blood glucose is in a normal range and you'll still see other symptoms of typical DKA like nausea and vomiting.

00:03:51 Stephen Small

Or fruity breath odor. And we can expect labs like ketones to be abnormally high, too.

00:03:58 Stephen Small

We think this is all caused by a combination of factors.

00:04:02 Stephen Small

Fasting increases acidic ketones in our blood.

00:04:06 Stephen Small

This can worsen with SGLT 2's, along with stress from surgery, because both of those also raise ketones.

00:04:14 Stephen Small

SGLT 2 inhibitors also increase urination of glucose and excessive urination can cause dehydration, so together, all of these can lead to decay symptoms.

00:04:30 Stephen Small

To prevent this, the American Diabetes Association and others recommend holding most of the SGLT 2 inhibitors 3 days before going to.

00:04:40 Stephen Small

OR.

00:04:41 Stephen Small

This gives the Med enough time to clear from the body.

00:04:46 Stephen Small

Now 1 exception here is ertugliflozin.

00:04:49 Stephen Small

It requires holding for four days instead because it has a longer half.

00:04:55 Stephen Small

Do this regardless of the indication, for example, still apply this to a patient taking these for heart failure instead of diabetes.

00:05:05 Stephen Small

So in Scotts case, we should tell him to expect to hold his canagliflozins in three days before the procedure.

00:05:12 Stephen Small

Let's also give Scott some other tips to think about here.

00:05:17 Stephen Small

Advise watching out for some of those DKA symptoms like nausea and fatigue.

00:05:22 Stephen Small

He should tell his doctor ASAP.

00:05:24 Stephen Small

He notices these.

00:05:26 Stephen Small

Keep in mind, too, some patients may want to proactively check their urine. Ketones at home pre op.

00:05:32 Stephen Small

Even if they're feeling well.

00:05:35 Stephen Small

But recommend they only check urine. Ketones if they feel unwell.

00:05:39 Stephen Small

These meds actually help reabsorb urine, ketones in the kidney, which causes falsely low levels, and could lead to some false reassurance.

00:05:49 Stephen Small

Post Op, you can also tell them to expect to restart his canagliflozin after he's done with all procedures, is stable, eating well, and has no other DKA risks.

00:06:02 Stephen Small

Let's move to Scott's glp one agonist next.

00:06:06 Stephen Small

I'm sure you know these have become very popular and these meds stimulate insulin release but also slow down stomach emptying.

00:06:14

Now.

00:06:15 Stephen Small

This stomach effect can help people feel full after a meal, but it can also cause nausea, vomiting and other GI issues.

00:06:23 Stephen Small

Including periob complications, for example, surgeons usually want the stomach to be empty before surgery, otherwise food in the stomach can be vomited during anesthesia, and the patient could choke or aspirate.

00:06:39 Stephen Small

These GI side effects can also be misdiagnosed as post op ileus, where the stomach and intestine don't transport food normally.

00:06:51 Stephen Small

Expect patients to hold their GLP-1 agonist before surgery if they have a higher aspiration risk.

00:06:58 Stephen Small

The medical team and patient may use shared decision making to talk through risks and decide whether to ultimately hold a GLP one.

00:07:07 Stephen Small

Higher risk situations include patients who are still titrating up their GLP1 dose or if they have current symptoms of slowed gastric emptying like abdominal pain or nausea.

00:07:19 Stephen Small

Having conditions that slow stomach emptying, like Parkinson's disease, can also be a risk.

00:07:25 Stephen Small

If the GOP one has decided to be held the length of time, though, depends on how often it's dosed.

00:07:33 Stephen Small

Doses should be held on the day of the procedure for products given daily or twice daily, and doses should be held one week prior. For weekly versions like semaglutide injection.

00:07:47 Stephen Small

Patients with a lower aspiration risk can likely continue their GOP one agonist period in some cases.

00:07:54 Stephen Small

Many patients report less GI side effects after the first month of being on a GLP one.

00:08:00 Stephen Small

So for patients tolerating long term therapy, you might see providers just take extra aspiration precautions during surgery instead of holding the GLP one.

00:08:12 Stephen Small

With that in mind, let's go back to Scott.

00:08:15 Stephen Small

You decide to clarify with him which exenatide type product he actually takes.

00:08:20 Stephen Small

He reports using the weekly version.

00:08:23 Stephen Small

You can also ask how long he's been taking it, he says. It's been about seven months without any side effects.

00:08:31 Stephen Small

He remembers he was told to hold his dose one week before surgery, which sounds appropriate.

00:08:38 Stephen Small

Priya also remind patients to note the date and time of their last GLP 1 dose.

00:08:45 Stephen Small

Also advised they write down the date and time of their last pre op meal.

00:08:50 Stephen Small

The surgery team may want this info to assess aspiration risk.

00:08:55 Stephen Small

And suggest bring in their home GLP one supply with them to use in the hospital.

00:09:00 Stephen Small

Hospitals are pretty unlikely to stock these because of their high cost.

00:09:05 Stephen Small

The GLP one likely won't restarted until post op nausea and vomiting resolve, since GLP ones could make that worse.

00:09:14 Stephen Small

Missed dose guidance can also.

00:09:15 Stephen Small

Here it can help us determine if we need to restart the GLP one.

00:09:20 Stephen Small

At a lower dose to avoid GI side effects. Again, for example, daily liraglutide should be restarted at a lower dose if more than three days have been missed.

00:09:33 Stephen Small

Now let's take a look at Metformin, which is another very popular diabetes Med.

00:09:39 Stephen Small

We're mostly concerned here with lactic acidosis as a periop complication.

00:09:44 Stephen Small

This is where lactic acid builds up in the body, causing symptoms like altered mental status.

00:09:49 Stephen Small

And it could be fatal.

00:09:51 Stephen Small

This can be caused by decreased metformin clearance by the kidneys, which increases metformin to toxic levels in the body.

00:10:00 Stephen Small

There are many things that happen around surgery that can injure the kidneys.

00:10:03 Stephen Small

Cause this?

00:10:05 Stephen Small

Think about risk factors like poor PO intake, dehydration or even renal E toxic meds like contrast dyes.

00:10:14 Stephen Small

To avoid this, expect metformin doses to be held the morning of surgery. But.

00:10:20 Stephen Small

There may be specific cases where doctors are OK with not stopping metformin.

00:10:26 Stephen Small

This includes short same day surgeries when we can trust the patient's kidneys of adequate function, and the patient has a low dehydration risk.

00:10:35 Stephen Small

Like being NPO for just one meal.

00:10:38 Stephen Small

Pre OP counsel patients to maintain adequate hydration before surgery.

00:10:44 Stephen Small

This can help keep their kidneys in top shape and post op. Patients need to be stable, eating well and have adequate kidney function to make sure metformin clears appropriately.

00:10:57 Stephen Small

Now to wrap things up, let's talk about insulin and sulfonylureas.

00:11:03 Stephen Small

Patients insulin needs decrease when they're fasting pre op because their glucose intake is lower. If we give the same amount of insulin as when they're eating, we could cause hypoglycemia and we all know dangerously low blood sugar can lead to unconsciousness, seizures and even death.

00:11:23 Stephen Small

We can also alley this same idea to sulfonylureas, but glipizide and glimepiride.

00:11:30 Stephen Small

Percephaloorhias expect patients to hold doses the day of the procedure and while fasting.

00:11:36 Stephen Small

And expect the same for short acting insulins like regular insulin or lispro.

00:11:43 Stephen Small

Remember, this applies to short acting insulins used in premixed products too, like combined NPH with regular insulin.

00:11:51 Stephen Small

What we do with these doses can depend on the patient's glucose level.

00:11:58 Stephen Small

But with medium and long-acting insulins, you'll see patients generally continue these on the procedure day.

00:12:05 Stephen Small

Their long action makes hypoglycemia risk lower.

00:12:09 Stephen Small

However, their dose will be reduced, for example.

00:12:13 Stephen Small

Clergy might be decreased by at least 20% the night before or morning of surgery.

00:12:19 Stephen Small

Here are some other points you can share here with patients advice. Checking glucose more frequently while fasting up to every two hours.

00:12:28 Stephen Small

Take this also as an opportunity with them to review hypoglycemia.

00:12:32 Stephen Small

Signs and symptoms and how to treat it.

00:12:35 Stephen Small

After the procedures are done, their glucose will still need close monitoring. If they stay in PO or have trouble eating postop, their insulin doses might be reduced to prevent hypoglycemia.

00:12:47 Stephen Small

And sulfonylureas generally can be restarted one or two days before discharge.

00:12:53 Stephen Small

Assuming the patient is eating and drinking well.

00:12:57 Stephen Small

In terms of general practice pearls, pharmacists can ask to see patients pre-op from the doctor if they have it.

00:13:05 Stephen Small

Spacing info might be included in there, and patients may just need your help understanding it.

00:13:10 Stephen Small

But we don't want to completely change a doctor's pre op plan without them.

00:13:16 Stephen Small

Contact their medical team if you have questions or you just need some clarity.

00:13:21 Stephen Small

Ask the patient if they need more home testing supplies, since they'll need to check their glucose frequently.

00:13:26 Stephen Small

And pharmacists, you can remind them their periopt glucose goal is typically between 100.

00:13:32 Stephen Small

And 180.

00:13:34 Stephen Small

For technicians, you can ask the patient if they need refills for Glucagon or glucose tabs.

00:13:39 Stephen Small

In case of hypoglycemia.

00:13:42 Stephen Small

And we can all reinforce patients bringing updated home Med list on the procedure day to help with transition of care.

00:13:50 Stephen Small

Be sure to check out our resource, perioperative management of diabetes online.

00:13:55 Stephen Small

It lists different diabetes Med classes along with tying recommendations and other considerations to help keep our patients safe around surgery.

00:14:06 Stephen Small

And use our chart, perioperative management of chronic meds to answer similar questions for Aces, Arbs, statins and more.

00:14:07 Narrator

We hope you enjoyed and gained practical insights from listening to this presentation.

00:14:12 Narrator

Be sure to follow or subscribe, rate, and review this show in your favorite podcast app. Or find the show on YouTube by searching for ‘TRC Healthcare’ or clicking the link in the show notes. While you’re there, check out our other TRC podcasts like Medication Talk and Rumor vs Truth.

00:14:30 Narrator

Also in the show notes, we’ve linked directly to a few of the excellent resources mentioned today available to subscribers of Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights. On those websites you’ll also find a lot more evidence-based, concise, yet comprehensive resources on this and other medication therapy topics. 

00:14:55 Narrator

If you aren’t already a subscriber… don’t miss out on these resources! Sign up today to stay ahead with trusted insights and tools. We are an industry leading, non-biased source of information and continuing education.

00:15:10 Narrator

And if you're a student, good news—students can access a free version of Pharmacist’s Letter, we’ve linked to that directly in the show notes as well… Check it out!

00:15:20 Narrator

Find out more about our product offerings at trchealthcare.com.

00:15:25 Narrator

You can also reach out to provide feedback or make suggestions by emailing us at ContactUs@trchealthcare.com. 

00:15:35 Narrator

Thanks for listening to Clinical Capsules!