Postprocedural management of adults with type 2 diabetes

After a procedure that is not long and complex, the patient’s usual antihyperglycaemic drugs (except metformin or SGLT2 inhibitors) can usually be restarted when their oral intake resumes. In general, the target blood glucose concentration is 5 to 10 mmol/L, aiming to avoid hypoglycaemia.

For patients at risk of periprocedural kidney dysfunction, metformin should not be restarted after a procedure until kidney function returns to baseline and the patient is eating and drinking normally.

SGLT2 inhibitors should be withheld periprocedurally to reduce the risk of diabetic ketoacidosis (DKA) (see Preprocedural management of noninsulin antihyperglycaemic drugs for adults with type 2 diabetes). An SGLT2 inhibitor should not be restarted after a procedure until the patient is eating and drinking normally, kidney function has returned to baseline, and the patient is close to discharge (usually 3 to 5 days after a procedure). Patients who have had a day procedure should not restart the SGLT2 inhibitor until they are eating and drinking normally and kidney function has returned to baseline; consider delaying restarting the SGLT2 inhibitor for a further 24 hours to reduce the risk of DKA, but also consider the potential for hyperglycaemia.

Any patient taking an SGLT2 inhibitor who becomes unwell in the week following a procedure (ie has abdominal pain, nausea, vomiting, fatigue or metabolic acidosis) should have their blood ketone concentration checked, even if their blood glucose concentrations are not elevated and the SGLT2 inhibitor was withheld periprocedurally. Blood glucose concentration may not be elevated in DKA associated with SGLT2 inhibitors, and a negative urinary ketone result does not exclude DKA.

Note: Check blood ketone concentrations in any patient who has taken an SGLT2 inhibitor and who becomes acutely unwell in the week following a procedure.

For patients with type 2 diabetes who require insulin after a procedure, a multiple daily injection (basal–bolus) insulin regimen is preferred. In general, the target blood glucose concentration is 5 to 10 mmol/L, aiming to avoid both hyperglycaemia and hypoglycaemia. See Multiple daily injection (basal–bolus) insulin regimen for further information about a multiple daily injection (basal–bolus) insulin regimen.

Note: Do not give rapid- or short-acting insulin according to a ‘sliding scale’ without basal insulin.

Do not give rapid- or short-acting insulin doses according to predefined blood glucose concentrations (‘sliding scale’) without basal insulin. Sliding scale insulin regimens used in isolation are associated with pronounced fluctuations in blood glucose concentrations and are prone to causing both significant hyperglycaemia and hypoglycaemia.