/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/cpg/,/clinical/cckm-tools/content/cpg/diabetes-and-endocrinology/,/clinical/cckm-tools/content/cpg/diabetes-and-endocrinology/related/,

/clinical/cckm-tools/content/cpg/diabetes-and-endocrinology/related/name-97504-en.cckm

201705121

page

100

UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Clinical Practice Guidelines,Diabetes and Endocrinology,Related

Diabetes Medication Adjustment (Ambulatory Procedures)

Diabetes Medication Adjustment (Ambulatory Procedures) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Diabetes and Endocrinology, Related


Last Updated 3/23/2017 | Last Reviewed 2/23/2017
Questions? Contact Inpatient Diabetes Quality Committee
This reference is meant to reflect best practice. Provider orders (or delegated authority) are required to enact.
All Patients
 If possible, schedule test early in the day.
 Monitor blood glucose frequently (before and after procedure). If procedure is longer than 1 hour, monitor blood glucose during the procedure (optimally, every hour).
 Hypoglycemia: Glucose tablets can be used by the patient at any time before or after the procedure if safe to swallow. Use IV dextrose during the procedure if the patient is sedated.
 Questions related to medication adjustment before/after contrast should be resolved by referring to UW Health Guideline: Contrast-Induced Nephropathy – Adult – Inpatient/Ambulatory.
Type 1 Diabetes
 Be sure there is always basal insulin prescribed (injections, pump, or insulin drip); ketoacidosis (“DKA”) can occur if insulin levels are not maintained.
 Correction insulin (sliding scales) should never be used as the sole insulin but instead used only as a supplement to the patient’s basal insulin regimen (glargine, NPH, or detemir).
Type 2 Diabetes
 Patients treated by diet alone should have blood glucose monitoring at minimum to recognize hyperglycemia and then treat as indicated.
 In general, oral hypoglycemic agents are omitted on the day of the procedure. Some oral medications need to be adjusted or omitted the day before the procedure if the diet will change, i.e. clear liquids.
 Patients using insulin will require insulin pre-procedure as noted below. Insulin should not be stopped. Ketoacidosis can occur even though the patient has type 2 diabetes.
MEDICATION PREP DAY PROCEDURE DAY RESTARTING DOSE
OR
AL

AG
EN
T
S
AN
D

NO
N-
IN
SU
L
IN

IN
J
E
CT
IB
L
E
S
Secretagogues: Sulfonylurea (glipizide, glyburide, glimepiride);
non-sulfa drugs (repaglinide, nateglinide)
Alpha-glucosidase: Acarbose (Precose®), Miglitol (Glyset®)
Amylin Analog: Pramlintide (Symlin®)
Hold if on clear liquids, NPO, or bowel prep needed Hold After procedure when eating
usual meals
Biguanides: Metformin, Metformin XR (extended release)
Hold if on clear liquids, NPO, or bowel prep needed Hold
Consider checking eGFR if
patient received contrast AND
has history of renal disease.
GLP-1 agonists: i.e., exenatide (Byetta®, Bydureon®), liraglutide
(Victoza®), dulaglutide (Trulicity®), albiglutide Hold if on clear liquids, NPO, or bowel prep needed Hold
After procedure when eating
usual meals
DPP-4 Inhibitors: “gliptins” – i.e. sitagliptin (Januvia®),
saxagliptin (Onglyza®), linagliptin (Tradjenta®), alogliptin
(Nesina®)
Hold if on clear liquids, NPO, or bowel prep needed Hold
TZDs: pioglitazone (Actos®), rosiglitazone (Avandia®) No restrictions Hold
SGLT-2 Inhibitors “flozins” – i.e., canagliflozin (Invokana®),
dapagliflozin (Farxiga®), empagliflozin (Jardiance®) No restrictions Hold
IN
SU
L
IN

Rapid-acting insulin analogs: lispro (Humalog®, Humalog® U-
200), aspart (Novolog®), glulisine (Apidra®) Hold if on clear liquids, NPO, or bowel prep needed.
(If patient uses carbohydrate-based insulin dosing for meals, insulin can
be taken to cover the carbs in the liquids.)
Hold
(may use to correct
hyperglycemia if patient uses
correction scale at home) After procedure when eating
usual meals Regular Insulin Hold if on clear liquids, NPO, or bowel prep needed.
(use to correct hyperglycemia if correction scale used at home)
Hold
(use to correct hyperglycemia if
correction scale used at home)
Intermediate-acting insulin
ξ Isophane (NPH)
Usual dose the night before preparation day. Prep day: if on clear liquids,
NPO, or bowel prep needed, ½ dose in the morning (if taking) and ½ of
usual evening dose.
½ dose in the morning After procedure when eating
usual meals
Long-acting
ξ Glargine (Lantus®, Basaglar®), Detemir (Levemir®), Degludec
(Tresiba® U-100)
Usual dose, no adjustment is required.
Use caution for those who use basal insulin ONLY without oral agents or insulin for meal coverage. These
patients may need 20-50% less than usual dose.
Continue with usual dose (or
resume usual dose if decrease
had been made pre-procedure)
Pre-mixed/combination insulins (e.g., 70/30, 75/25) Usual dose the night before preparation day. Prep day: if on clear liquids,
NPO, or bowel prep needed, ⅓ to ½ dose in morning & evening ⅓ dose in the morning
After procedure when eating
usual meals
Concentrated insulin
ξ U-500, Degludec U-200 (Tresiba® U-200), Glargine U-300
(Toujeo®)
NPO adjustment for concentrated insulin types vary. Diabetes/endocrine specialists should be consulted to
determine adjustment. (Duration of action: U-500: 12 hours, U-200: 36 hours, U-300: 42+ hours)
After procedure when eating
usual meals
INSULIN PUMP: Rapid-acting insulin analogs (lispro, aspart,
glulisine) are used in insulin pumps. On occasion, Regular insulin
is used. If U-500 is used, contact patient’s endocrinologist.
No change in basal insulin or patient can use a temporary basal decrease to maintain target BG. Bolus insulin is
not given unless for hyperglycemia. REMOVE PUMP before most procedures (i.e., MRI, CT),
procedure/surgery longer than 2 hours, and/or other contraindications. (See Policy 10.25) SQ or IV insulin
infusion MUST be given before the pump is removed.
Resume usual programming
when eating (pt should correct
for hyperglycemia as long as
patient can independently
manage pump.

Medication Adjustment for Patients who are NPO
Diabetes Medication Adjustment: Ambulatory Procedures

Association AD. Professional Practice Committee for the
Standards of Medical Care in Diabetes-2017. Diabetes Care.
Jan 2017;40 Suppl 1:S1-135.