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
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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
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00:15:10 Narrator
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00:15:20 Narrator
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00:15:25 Narrator
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00:15:35 Narrator
Thanks for listening to Clinical Capsules!
