Note: The following recommendations provide general
guidance for the management of diabetes during surgery.
Local protocols and guidelines should be followed where
Elective surgery—minor procedures in patients with good
g Patients usually treated with insulin who have good
glycaemic control (HbA1c less than 69 mmol/mol or 8.5 %)
and are undergoing minor procedures, can be managed during
the operative period by adjustment of their usual insulin
regimen, which should be adjusted depending on the type of
insulin usually prescribed, following detailed local protocols
(which should also include intravenous fluid management,
monitoring and control of electrolytes and avoidance of
hyperchloraemic metabolic acidosis). On the day before the
surgery, the patient’s usual insulin should be given as
normal, other than once daily long-acting insulin analogues,
which should be given at a dose reduced by 20 %. l
Elective surgery—major procedures or poor glycaemic control
g Patients usually treated with insulin, who are either
undergoing major procedures (surgery requiring a long
fasting period of more than one missed meal) or whose
diabetes is poorly controlled, will usually require a variable
rate intravenous insulin infusion (continued until the
patient is eating/drinking and stabilised on their previous
The aim is to achieve and maintain glucose concentration
within the usual target range (6–10 mmol/litre; but up to
12 mmol/litre is acceptable) by infusing a constant rate of
glucose-containing fluid as a substrate, while also infusing
insulin at a variable rate. Detailed local protocols should be
consulted. In general, the following steps should be
. on the day before surgery, once daily long-acting insulin
analogues should be given at 80 % of the usual dose;
otherwise the patient’s usual insulin should be given as
. on the day of surgery and throughout the intra-operative
period, once daily long-acting insulin analogues should be
continued at 80 % of the usual dose; all other insulin
should be stopped until the patient is eating and drinking
. on the day of surgery, start an intravenous substrate
infusion of potassium chloride with glucose and sodium
chloride p. 1039 (based on serum electrolytes which must
be measured frequently), and infuse at a rate appropriate
to the patient’s fluid requirements. To prevent
hypoglycaemia, this infusion must not be stopped while
the insulin infusion is running;
. a variable rate intravenous insulin infusion of soluble
human insulin p. 712 in sodium chloride 0.9 % p. 1040
(made either according to locally agreed protocols or using
prefilled syringes) should be given via a syringe pump at an
should be taken to ensure that the intravenous insulin
infusion rate is correct for at least the first 12 hours; the
insulin infusion rate should be adjusted according to local
protocol to maintain blood-glucose concentrations within
the usual target range (6–10 mmol/litre; up to
checked every hour, to prevent a drop below 4 mmol/litre.
If blood-glucose drops below 4 mmol/litre, intravenous
glucose 20 % should be adjusted and blood-glucose
checked every 15 minutes, until blood-glucose is above
consider other signs of diabetic ketoacidosis (see Diabetic
Conversion back to a subcutaneous insulin should not
begin until the patient can eat and drink without nausea or
insulin requirements can change due to post-operative
stress, infection or altered food intake.
Previous subcutaneous basal-bolus regimens, should be
restarted when the first postoperative meal-time insulin
dose is due (e.g. with breakfast or lunch); doses may need
adjustment due to postoperative stress, infection or altered
food intake. The variable rate intravenous insulin infusion
and intravenous fluids should be continued until
30–60 minutes after the first meal-time short-acting insulin
dose. If the patient was previously on a long-acting insulin
analogue, this should have been continued throughout the
operative period at 80 % of the normal dose, and should now
just continue at that same dose until the patient leaves
hospital; only the short-acting insulin needs to be restarted
Previous subcutaneous twice-daily mixed insulin
regimens, should be restarted before breakfast or an
evening meal (not at any other time). The variable rate
intravenous insulin infusion should be maintained for
30–60 minutes after the first subcutaneous insulin dose has
Patients who were previously managed with a
continuous subcutaneous insulin infusion should be
referred to a specialist team. The subcutaneous infusion
should be restarted at the normal basal rate, not at bedtime,
and the insulin infusion continued until the next meal bolus
Patients not previously prescribed insulin, who are to
start a subcutaneous insulin regimen post-surgery, should
have an insulin dose calculated with advice from a specialist
diabetes team, considering the patient’s sensitivity to
insulin, degree of glycaemic control, weight, age, and the
average hourly insulin dose used in the peri-operative
g Patients with diabetes (type 1 and 2) requiring
emergency surgery, should always have their blood-glucose,
blood or urinary ketone concentration, serum electrolytes
and serum bicarbonate checked before surgery. If ketones
are high or bicarbonate is low, blood gases should also be
checked. If ketoacidosis is present, recommendations for
Diabetic ketoacidosis p. 689 should be followed immediately,
and surgery delayed if possible. If there is no acidosis,
intravenous fluids and an insulin infusion should be started
and managed as for major elective surgery (above). l
Use of antidiabetic drugs during surgery
g Manipulation of antidiabetic drug may not be
appropriate for all surgery or for all patients; particularly
when fasting time is more than one missed meal, in patients
with poor glycaemic control, and when there is risk of renal
injury. In these cases, a variable rate intravenous insulin
p. 712 infusion should be used as for major elective surgery
(above), and usual antidiabetic medication adjusted in the
peri-operative period. Insulin is almost always required in
medical and surgical emergencies.
When insulin is required and given during surgery,
acarbose p. 692, meglitinides, sulfonylureas, pioglitazone
p. 710, dipeptidyl peptidase-4 inhibitors (gliptins) and
sodium glucose co-transporter 2 inhibitors should be
stopped once the insulin infusion is commenced and not
restarted until the patient is eating and drinking normally.
Glucagon-like peptide-1 receptor agonists can be continued
as normal during the insulin infusion.
adjust antidiabetic drugs to avoid a switch to a variable rate
intravenous insulin infusion; normal drug treatment can
690 Diabetes mellitus and hypoglycaemia BNF 78
In suitable cases, acarbose, nateglinide p. 701 and
repaglinide p. 702 can be continued with just the dose
omitted on the morning of surgery if fasting (the morning
dose may be given if the patient is not fasting and surgery is
Pioglitazone, dipeptidylpeptidase-4 inhibitors
(gliptins) and glucagon-like peptide-1 receptor agonists
can be taken as normal during the whole peri-operative
Sodium glucose co-transporter 2 inhibitors should be
omitted on the day of surgery and not restarted until the
patient is stable; their use during periods of dehydration and
acute illness is associated with an increased risk of
developing diabetic ketoacidosis.
Sulfonylureas are associated with hypoglycaemia in the
fasted state and therefore should always be omitted on the
day of surgery until the patient is eating and drinking again.
Capillary blood-glucose should be checked hourly. If
hyperglycaemia occurs, an appropriate dose of subcutaneous
rapid-acting insulin may be given. A second dose may be
given 2 hours later, and a variable rate intravenous insulin
infusion considered if hyperglycaemia persists.
Metformin hydrochloride p. 692 is renally excreted; renal
impairment may lead to accumulation and lactic acidosis
during surgery. If only one meal will be missed during
surgery, and the patient has an eGFR greater than
60 mL/minute/1.73m2 and a low risk of acute kidney injury
(and the procedure does not involve administration of
contrast media), it may be possible to continue metformin
hydrochloride throughout the peri-operative period—just
the lunchtime dose should be omitted if the usual dose is
If the patient will miss more than one meal or there is
significant risk of the patient developing acute kidney injury,
infusion should be started if the metformin hydrochloride
dose is more than once daily. Otherwise insulin should only
be started if blood-glucose concentration is greater than
12 mmol/litre on two consecutive occasions. Metformin
should not be recommenced until the patient is eating and
drinking again, and normal renal function has been assured.
There is no need to stop metformin hydrochloride after
contrast medium in patients missing only one meal or who
have an eGFR greater than 60 mL/minute/1.73m2
medium is to be used, and eGFR is less than
, metformin should be omitted on the
day of the procedure and for the following 48 hours. l
Use of antidiabetic drugs during medical illness
Manufacturers of some antidiabetic drugs recommend that
they may need to be replaced temporarily with insulin during
intercurrent illness when the drug is unlikely to control
hyperglycaemia (such as myocardial infarction, coma, severe
infection, trauma and other medical emergencies). Consult
individual product literature.
Sodium glucose co-transporter 2 inhibitors are associated
with increased risk of developing diabetic ketoacidosis
during periods of dehydration, stress, surgery, trauma, acute
medical illness or any other catabolic state, and should be
used with caution during these times. The MHRA has advised
(2016) that these drugs should be temporarily stopped in
patients who are hospitalised for acute serious illness until
the patient is medically stable.
Diabetes in pregnancy is associated with increased risks to
the woman (such as pre-eclampsia and rapidly worsening
retinopathy), and to the developing fetus, compared with
pregnancy in non-diabetic women. Effective blood-glucose
control before conception and throughout pregnancy
reduces (but does not eliminate) the risk of adverse
outcomes such as miscarriage, congenital malformation,
stillbirth, and neonatal death.
Management of pre-existing diabetes
g Women with pre-existing diabetes who are planning on
becoming pregnant should aim to keep their HbA1c
concentration below 48 mmol/mol (6.5%) if possible without
causing problematic hypoglycaemia. Any reduction towards
this target is likely to reduce the risk of congenital
Women with pre-existing diabetes who are planning to
become pregnant should be advised to take folic acid at the
dose for women who are at high-risk of conceiving a child
with a neural tube defect, see folic acid p. 1025. h
g All oral antidiabetic drugs, except metformin
hydrochloride p. 692, should be discontinued before
pregnancy (or as soon as an unplanned pregnancy is
identified) and substituted with insulin therapy. Women
with diabetes may be treated with metformin hydrochloride
p. 692 [unlicensed in type 1 diabetes] as an adjunct or
alternative to insulin in the preconception period and during
hydrochloride p. 692 can be continued, or glibenclamide
All other antidiabetic drugs should be avoided while breastfeeding. h
Limited evidence suggests that the rapid-acting insulin
analogues (insulin aspart p. 713 and insulin lispro p. 714) can
be associated with fewer episodes of hypoglycaemia, a
reduction in postprandial glucose excursions and an
improvement in overall glycaemic control compared with
have good blood-glucose control before pregnancy with the
long-acting insulin analogues (insulin detemir p. 717 or
insulin glargine p. 718), it may be appropriate to continue
using them throughout pregnancy.
Continuous subcutaneous insulin infusion p. 712 (insulin
pump therapy) may be appropriate for pregnant women who
have difficulty achieving glycaemic control with multiple
daily injections of insulin p. 712 without significant disabling
All women treated with insulin p. 712 during pregnancy
should be aware of the risks of hypoglycaemia, particularly in
the first trimester, and should be advised to always carry a
fast-acting form of glucose, such as dextrose tablets or a
glucose-containing drink. Pregnant women with Type 1
diabetes p. 684 should also be prescribed glucagon p. 724 for
Women with pre-existing diabetes treated with insulin
p. 712 during pregnancy are at increased risk of
hypoglycaemia in the postnatal period and should reduce
their insulin immediately after birth. Blood-glucose levels
should be monitored carefully to establish the appropriate
Medication for diabetic complications
g Angiotensin-converting enzyme inhibitors and
angiotensin II receptor antagonists should be discontinued
and replaced with an alternative antihypertensive suitable
for use in pregnancy before conception or as soon as
pregnancy is confirmed (see Hypertension in pregnancy under
Hypertension p. 140). Statins should not be prescribed
during pregnancy and should be discontinued before a
g Women with gestational diabetes who have a fasting
plasma glucose below 7 mmol/litre at diagnosis, should first
attempt a change in diet and exercise alone in order to
reduce blood-glucose. If blood-glucose targets are not met
within 1 to 2 weeks, metformin hydrochloride below may be
prescribed [unlicensed use]. Insulin p. 712 may be prescribed
if metformin is contra-indicated or not acceptable, and may
also be added to treatment if metformin is not effective
Women who have a fasting plasma glucose above
7 mmol/litre at diagnosis should be treated with insulin
p. 712 immediately, with or without metformin
hydrochloride below, in addition to a change in diet and
Women who have a fasting plasma glucose between 6 and
6.9 mmol/litre alongside complications such as macrosomia
or hydramnios should be considered for immediate insulin
p. 712 treatment, with or without metformin hydrochloride
Glibenclamide p. 709 [unlicensed use] may be considered
for women from 11 weeks gestation (after organogenesis)
who cannot tolerate metformin, or for those in whom
metformin is not effective and do not wish to have insulin
Women with gestational diabetes should discontinue
hypoglycaemic treatment immediately after giving birth. h
Management of diabetes. Scottish Intercollegiate Guidelines
Network. Clinical guideline 116. March 2010 (updated
www.sign.ac.uk/assets/sign116.pdf
Diabetes in pregnancy: management from preconception
to the postnatal period. National Institute for Health and
Care Excellence. Clinical guideline NG3. February 2015.
BLOOD GLUCOSE LOWERING DRUGS › ALPHA
l DRUG ACTION Acarbose, an inhibitor of intestinal alpha
glucosidases, delays the digestion and absorption of starch
and sucrose; it has a small but significant effect in
Diabetes mellitus inadequately controlled by diet or by
diet with oral antidiabetic drugs
▶ Adult: Initially 50 mg daily, then increased to 50 mg
3 times a day for 6–8 weeks, then increased if necessary
to 100 mg 3 times a day (max. per dose 200 mg 3 times
l CAUTIONS May enhance hypoglycaemic effects of insulin
and sulfonylureas (hypoglycaemic episodes may be treated
with oral glucose but not with sucrose)
l INTERACTIONS → Appendix 1: acarbose
▶ Common or very common Diarrhoea (may need to reduce
dose). gastrointestinal discomfort. gastrointestinal
▶ Rare or very rare Hepatic disorders . oedema
▶ Frequency not known Acute generalised exanthematous
pustulosis (AGEP).thrombocytopenia
SIDE-EFFECTS, FURTHER INFORMATION Antacids
containing magnesium and aluminium salts unlikely to be
beneficial for treating side effects.
l HEPATIC IMPAIRMENT Manufacturer advises avoid in
l RENAL IMPAIRMENT Avoid if eGFR less than
l MONITORING REQUIREMENTS Monitor liver function.
l DIRECTIONS FOR ADMINISTRATION Tablets should be
chewed with first mouthful of food or swallowed whole
with a little liquid immediately before food.
l PATIENT AND CARER ADVICE Antacids unlikely to be
beneficial for treating side-effects. To counteract possible
hypoglycaemia, patients receiving insulin or a
sulfonylurea as well as acarbose need to carry glucose (not
sucrose—acarbose interferes with sucrose absorption).
Patients should be given advice on how to administer
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Acarbose 50 mg Acarbose 50mg tablets | 90 tablet P £15.00 DT
Acarbose 100 mg Acarbose 100mg tablets | 90 tablet P £27.00
BLOOD GLUCOSE LOWERING DRUGS ›
Metformin hydrochloride 06-Jun-2017
l DRUG ACTION Metformin exerts its effect mainly by
decreasing gluconeogenesis and by increasing peripheral
utilisation of glucose; since it acts only in the presence of
endogenous insulin it is effective only if there are some
residual functioning pancreatic islet cells.
Type 2 diabetes mellitus [monotherapy or in combination
with other antidiabetic drugs (including insulin)]
▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES
▶ Child 10–17 years (specialist use only): Initially 500 mg
once daily, dose to be adjusted according to response at
intervals of at least 1 week, maximum daily dose to be
given in 2–3 divided doses; maximum 2 g per day
▶ Adult: Initially 500 mg once daily for at least 1 week,
dose to be taken with breakfast, then 500 mg twice
daily for at least 1 week, dose to be taken with breakfast
and evening meal, then 500 mg 3 times a day, dose to
be taken with breakfast, lunch and evening meal;
▶ BY MOUTH USING MODIFIED-RELEASE MEDICINES
▶ Adult: Initially 500 mg once daily, then increased if
necessary up to 2 g once daily, dose increased
gradually, every 10–15 days, dose to be taken with
evening meal, alternatively increased to 1 g twice daily,
dose to be taken with meals, alternative dose only to be
used if control not achieved with once daily dose
regimen. If control still not achieved then change to
692 Diabetes mellitus and hypoglycaemia BNF 78
Type 2 diabetes mellitus [reduction in risk or delay of
▶ BY MOUTH USING MODIFIED-RELEASE MEDICINES
▶ Adult 18–74 years: Initially 500 mg once daily, then
increased if necessary up to 2 g once daily, dose
increased gradually, every 10–15 days, dose to be taken
with evening meal, for further information on risk
factors—consult product literature
▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES
▶ Adult: Initially 500 mg once daily for 1 week, dose to be
taken with breakfast, then 500 mg twice daily for
1 week, dose to be taken with breakfast and evening
meal, then 1.5–1.7 g daily in 2–3 divided doses
▶ In adults g Based on clinical experience of increased
licence. lNot licensed for polycystic ovary syndrome.
l CONTRA-INDICATIONS Acute metabolic acidosis (including
lactic acidosis and diabetic ketoacidosis)
l CAUTIONS Risk factors for lactic acidosis
▶ Risk factors for lactic acidosis Manufacturer advises caution
in chronic stable heart failure (monitor cardiac function),
and concomitant use of drugs that can acutely impair renal
function; interrupt treatment if dehydration occurs, and
avoid in conditions that can acutely worsen renal function,
l INTERACTIONS → Appendix 1: metformin
▶ Common or very common Abdominal pain . appetite
decreased . diarrhoea (usually transient). gastrointestinal
disorder. nausea .taste altered . vomiting
SIDE-EFFECTS, FURTHER INFORMATION Gastro-intestinal
side-effects are initially common with metformin, and may
persist in some patients, particularly when very high doses
are given. A slow increase in dose may improve
diabetes should discontinue treatment after giving birth.
l BREAST FEEDING May be used during breast-feeding in
women with pre-existing diabetes.
l HEPATIC IMPAIRMENT Withdraw if tissue hypoxia likely.
▶ In adults Manufacturer advises avoid if eGFR is less than
▶ In children Manufacturer advises avoid if estimated
glomerular filtration rate is less than
Dose adjustments ▶ In children Manufacturer advises
consider dose reduction in moderate impairment.
▶ In adults Manufacturer advises reduce dose in moderate
impairment—consult product literature.
l MONITORING REQUIREMENTS Determine renal function
before treatment and at least annually (at least twice a
year in patients with additional risk factors for renal
impairment, or if deterioration suspected).
l PRESCRIBING AND DISPENSING INFORMATION
metformin modified release; not suitable if dose of
standard-release tablets more than 2 g daily.
l PATIENT AND CARER ADVICE Manufacturer advises that
patients and their carers should be informed of the risk of
lactic acidosis and told to seek immediate medical
attention if symptoms such as dyspnoea, muscle cramps,
abdominal pain, hypothermia, or asthenia occur.
Medicines for Children leaflet: Metformin for diabetes
www.medicinesforchildren.org.uk/metformin-diabetes
l NATIONAL FUNDING/ACCESS DECISIONS
Scottish Medicines Consortium (SMC) decisions
The Scottish Medicines Consortium has advised (September
2009) that Glucophage ® SR is accepted for restricted use
within NHS Scotland for the treatment of type 2 diabetes
tablet allows the use of a dose of metformin not previously
tolerated, or in patients for whom a once daily preparation
offers a clinically significant benefit.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: capsule, oral
CAUTIONARY AND ADVISORY LABELS 21, 25
▶ Metformin hydrochloride (Non-proprietary)
▶ Glucient SR (Consilient Health Ltd)
Metformin hydrochloride 750 mg Glucient SR 750mg tablets |
▶ Glucophage SR (Merck Serono Ltd)
Metformin hydrochloride 1 gram Glucophage SR 1000mg tablets |
28 tablet P £3.20 | 56 tablet P £6.40 DT = £6.40
▶ Metabet SR (Actavis UK Ltd, Morningside Healthcare Ltd)
▶ Metuxtan SR (Accord Healthcare Ltd)
Metformin hydrochloride 500 mg Metuxtan SR 500mg tablets |
28 tablet P £1.99 | 56 tablet P £5.32 DT = £4.00
▶ Sukkarto SR (Morningside Healthcare Ltd)
Metformin hydrochloride 500 mg Sukkarto SR 500mg tablets | 56 tablet P £2.38 DT = £4.00
Metformin hydrochloride 1 gram Sukkarto SR 1000mg tablets | 56 tablet P £3.82 DT = £6.40
▶ Yaltormin SR (Wockhardt UK Ltd)
Metformin hydrochloride 750 mg Yaltormin SR 750mg tablets |
28 tablet P £1.44 | 56 tablet P £2.88 DT = £6.40
CAUTIONARY AND ADVISORY LABELS 21
▶ Metformin hydrochloride (Non-proprietary)
▶ Glucophage (Merck Serono Ltd)
Metformin hydrochloride 500 mg Glucophage 500mg tablets | 84 tablet P £2.88
Metformin hydrochloride 850 mg Glucophage 850mg tablets | 56 tablet P £3.20 DT = £1.56
CAUTIONARY AND ADVISORY LABELS 21
▶ Metformin hydrochloride (Non-proprietary)
Metformin hydrochloride 100 mg per 1 ml Metformin 500mg/5ml
oral solution sugar free sugar-free | 100 ml P £4.55–£10.50
sugar-free | 150 ml P £60.00 DT = £6.83
Metformin hydrochloride 170 mg per 1 ml Metformin 850mg/5ml
oral solution sugar free sugar-free | 150 ml P £19.95 DT = £19.95
Metformin hydrochloride 200 mg per 1 ml Metformin 1g/5ml oral
solution sugar free sugar-free | 150 ml P £23.48–£24.00 DT =
BLOOD GLUCOSE LOWERING DRUGS ›
DIPEPTIDYLPEPTIDASE-4 INHIBITORS (GLIPTINS)
l DRUG ACTION Inhibits dipeptidylpeptidase-4 to increase
insulin secretion and lower glucagon secretion.
Type 2 diabetes mellitus in combination with other
antidiabetic drugs (including insulin) if existing
treatment fails to achieve adequate glycaemic control
▶ Adult: 25 mg once daily, for further information on use
with other antidiabetic drugs—consult product
DOSE ADJUSTMENTS DUE TO INTERACTIONS
▶ Dose of concomitant sulfonylurea or insulin may need
▶ Caution with use in combination with both metformin
and pioglitazone—risk of hypoglycaemia (dose of
metformin or pioglitazone may need to be reduced).
l CONTRA-INDICATIONS Ketoacidosis
l CAUTIONS History of pancreatitis . not recommended in
moderate to severe heart failure (limited experience)
l INTERACTIONS → Appendix 1: alogliptin
▶ Common or very common Abdominal pain . gastrooesophageal reflux disease . headache . increased
risk of infection . skin reactions
▶ Frequency not known Angioedema . hepatic function
abnormal . pancreatitis acute . Stevens-Johnson syndrome
SIDE-EFFECTS, FURTHER INFORMATION Discontinue if
symptoms of acute pancreatitis occur such as persistent,
l ALLERGY AND CROSS-SENSITIVITY Contra-indicated if
history of serious hypersensitivity to dipeptidylpeptidase4 inhibitors.
l PREGNANCY Manufacturer advises avoid—no information
l BREAST FEEDING Avoid—present in milk in animal studies.
l HEPATIC IMPAIRMENT Manufacturer advises avoid in
severe impairment—no information available.
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