Perioperative challenges in management of diabetic patients undergoing non-cardiac surgery

Table 1 Preoperative medication-management in diabetic patients (dosages may need to be individualized to the patient)

Drugs	Day before surgery	Day of surgery
Metformin, Sulfonylurea (oral hypoglycemics)	Daily same dose	Hold on the day of surgery
Canaglifozin, Dapagliflozin, Empagliflozin (SGLT2 inhibitors)	Stop 3 d before surgery	Hold on the day of surgery
Ertuglozin (SGLT2 inhibitor)	Stop 4 d before surgery	Hold on the day of surgery
Injectable non-insulins	Normal dose the night before surgery	Hold on the day of surgery
Insulin pump	Depending on the insulin pump protocol	Depending on the insulin pump protocol
Levemir, Lantus, NPH (long-acting basal insulin)	Normal dose the night before surgery	Half the normal dose in the morning of surgery
Combination of long and short acting (mixed insulin)	Normal dose the night before surgery	Depending to the fasting blood glucose: If > 200 mg/dL: Take half of the normal dose; If < 200 mg/dL: No insulin

SGLT2: Sodium-glucose cotransporter 2. NPH: Neutral protamine hagedorn.

Table 2 Insulin treatment on the day of surgery

Insulin types	Regiment on the day of surgery
Lantus/Toujeo, Tresiba, Levemir (long-acting insulins)	Half dose of normal in the morning of surgery
NPH-insulin (intermediate insulin)	Half dose of normal in the morning of surgery
Inulin aspart protamine, insulin aspart; Insulin lispro protamine, insulin lispro; Insulin neutral protamine hagedorn and insulin regular (all mixed insulin)	Depending to the blood glucose: If > 200 mg/dL: Take half of the normal dose in the morning; If < 200 mg/dL: No insulin
All models of insulin pumps: Endocrinology consult recommended, except patient ambulatory	Basal rate until operation, continue with iv insulin during surgery