Inpatient diabetes guidelines (Guidelines)

• Actrapid
• NovoRapid
• Humalog
• Apidra
• Humulin S
• Insuman Rapid
• Fiasp
• Hypurin Porcine Neutral
• (Hypurin Bovine Neutral: NB discontinued)

• Lantus (once daily)
• Levemir (once or twice daily)
• Humulin I (once or twice daily)
• Tresiba (once daily; ultra-long acting, action beyond 42 hours: seek specialist diabetes team input if patient admitted on Tresiba)
• Insulatard (once or twice daily)
• Insuman Basal (once or twice daily)
• Toujeo (once daily)
• Abasaglar (once daily)

• Novomix 30
• Humulin M3
• Humalog Mix 25/50
• Insuman Comb 15/25/50

Insulin

Day before going into hospital

Day of surgery

Surgery in morning

Surgery in afternoon

If VRIII being used

Long-acting: Morning

Eg: Lantus, Levemir, Humulin I, Tresiba, Insulatard, Insuman Basal, Toujeo, Abasaglar

Take as normal

Reduce insulin dose by 20%. 

Reduce insulin dose by 20%.

Blood glucose will be checked on admission.

Resume normal insulin the morning after the surgery or procedure, if eating and drinking.

Continue at 80% of usual dose

Long-acting: Evening

Eg: Lantus, Levemir, Humulin I, Tresiba, Insulatard, Insuman Basal, Toujeo, Abasaglar

Reduce dose by 20%: Lantus, Levemir, Tresiba, Toujeo, Abasaglar

Take as normal: Humulin I, Insulatard, Insuman Basal

Resume normal insulin with evening meal if patient able to manage fluids and a snack after surgery.

For more prolonged surgery or if post-operative nausea and vomiting, monitor blood glucose – VRIII may be required.

Resume normal insulin with evening meal if patient able to manage fluids and a snack after surgery

For more prolonged surgery or if post-operative nausea and vomiting, monitor blood glucose – VRIII may be required.

Continue at 80% of usual dose

Twice or three times daily mix

Eg: Novomix 30, Humulin M3, Humalog Mix 25, Humalog Mix 50, Insuman Comb 15, Insuman Comb 25, Insuman Comb 50

Take as normal

Take half normal dose in the morning.

Check blood glucose on admission. VRIII may be required until patient resumes diet.

For more prolonged surgery or if post-operative nausea and vomiting, monitor blood glucose – VRIII may be required.

If patient able to manage fluids and a snack after surgery, resume normal dose with evening meal (or with lunch, if taking three times daily insulin).

Take half normal dose in the morning. 

If patient receiving three times daily mix insulin, omit lunchtime dose.

Check blood glucose on admission. VRIII may be required until patient resumes diet.

For more prolonged surgery or if post-operative nausea and vomiting, monitor blood glucose – VRIII may be required.

If patient able to manage fluids and a snack after surgery, resume normal dose with evening meal.

Stop until eating and drinking normally

2, 3, 4 or 5 injections daily
“Basal bolus” regimens

Any combination of background insulin combined with short-acting insulin at mealtimes

Long-acting insulins:

Eg: Lantus, Levemir, Humulin I, Tresiba, Insulatard, Insuman Basal, Toujeo, Abasaglar

Short-acting insulins:

Eg: Actrapid, Novorapid, Humalog, Apidra, Humulin S, Insuman Rapid, Fiasp, Hypurin Porcine Neutral
(Hypurin Bovine Neutral: discontinued)

Long acting insulin:

Morning: Take as normal

Evening: Reduce dose by 20% (Lantus, Levemir, Tresiba, Toujeo and Abasaglar only)

For other-long acting insulins: take normal dose (Humulin I, Insulatard, Insuman Basal)

Long-acting insulin:

Morning: Reduce dose by 20%.   Blood glucose will be checked on admission.

Resume normal insulin the morning after the surgery or procedure, if eating and drinking.

Evening: Resume normal insulin with evening meal if patient able to manage fluids and a snack after surgery.

For more prolonged surgery or if post-operative nausea and vomiting, monitor blood glucose – VRIII may be required.

Long-acting insulin:

Morning: Reduce dose by 20%. Blood glucose will be checked on admission.

Resume normal insulin the morning after the surgery or procedure, if eating and drinking.

Evening: Resume normal insulin with evening meal if patient able to manage fluids and a snack after surgery.

For more prolonged surgery or if post-operative nausea and vomiting, monitor blood glucose – VRIII may be required.

Continue long acting background insulin at 80% of usual dose

Short acting insulin: take as normal day before surgery.

Do NOT take short-acting insulin if NO breakfast is eaten. 

If patient able to manage fluids and a snack after surgery, restart short-acting insulin with lunch.

For more prolonged surgery or if post-operative nausea and vomiting, monitor blood glucose – VRIII may be required.

Take usual morning dose of short-acting insulin if breakfast is eaten. 
Do NOT take lunchtime dose.

If patient able to manage fluids and a snack after your surgery, restart short-acting insulin with evening meal

For more prolonged surgery or if post-operative nausea and vomiting, monitor blood glucose – VRIII may be required.

Stop until eating and drinking normally

Medication

Day before going into hospital

Day of surgery

AM surgery

PM surgery

After surgery

Specific considerations

Metformin

No bowel prep: Take as normal

Bowel prep:

Omit all doses

Omit all doses

Omit all doses

Recommence 48 hours after surgery (see specific considerations)

Withhold until 48 hours post-operation.  Resume if patient eating and drinking, ensure eGFR>40mL/min/1.73m² , serum creatinine <150micromol/L, no sepsis, no overt heart failure and no hypovolaemia.

Sulfonylureas

Eg: gliclazide, glipizide, glibenclamide, glimeperide

Take as normal

Omit morning dose

Omit morning dose. 

If taken twice daily: take evening dose only if eating

Recommence when eating and drinking normally

Pioglitazone

Take as normal

Omit on day of surgery

Omit on day of surgery

Recommence when eating and drinking normally

DPP-4 inhibitor

Eg: sitagliptin, vidagliptin, saxagliptin, alogliptin, linagliptin

Take as normal

Omit morning dose

Omit morning dose

Recommence when eating and drinking normally

GLP-1, GIP/GLP-1 

Eg: exenatide, liraglutide, lixisenatide, dulaglutide, semaglutide tirzepatide

Take as normal

Omit all doses

Omit all doses

Recommence when eating and drinking normally

If pancreatitis is suspected promptly discontinue

If eGFR < 30mL/min/1.73m² do not use.

SGLT-2 inhibitors

Eg: dapagliflozin, canagliflozin, empagliflozin

Omit all doses

Omit on day of surgery

Omit on day of surgery

Treatment may be restarted once fully recovered from surgery

Rare but serious cases of diabetic ketoacidosis have been reported in patients on SGLT inhibitor treatment for Type 2 diabetes. The risk of diabetic ketoacidosis must be considered in the event of non- specific symptoms such as nausea, vomiting, anorexia, abdominal pain, excessive thirst, difficulty breathing, confusion, unusual fatigue or sleepiness.  Treatment should be interrupted in patients who are hospitalised for major surgical procedures or acute serious medical illnesses.  In both cases, treatment with SGLT inhibitors can be restarted once the patient’s condition has stabilised.

Take as normal

Omit morning dose if breakfast not taken

Take morning dose if eating.  Do not take lunchtime dose

Recommence when eating and drinking normally

Meglitinide

Eg: repaglinide or nateglinide

Take normal

Omit morning dose if breakfast not taken

Take morning dose if eating breakfast

Recommence when eating and drinking normally