Can I get off my diabetes medication?

An operation is due - what is important now?

A hospital stay and an operation are imminent. That means stress - and it affects blood sugar. How do people with diabetes get through these difficult times safely and with as little complications as possible?

Emma L., 78 years old, had had increasing pain in her right hip in recent years, so that she could hardly go for a walk - she had always liked to do that. She had coxarthrosis, the orthopedist had told her after several examinations. With a heavy heart, but hoping to go for a walk again, she had agreed to an operation. Emma L. had gained 10 kg in the past few years. During the preliminary examinations for the operation, the clinic doctor found an elevated blood sugar level (180 mg / dl (10.0 mmol / l). "How long have you had diabetes?" He asked. Emma L. did not know that she had diabetes at all The doctor suspected: "Probably due to stress - from the fear of the operation and the pain." After the operation, which had gone well, Emma L. still had fasting values ​​of around 140 mg / dl (7.8 mmol / l With a small dose of metformin in the evening (500 mg), the fasting values ​​were back to around 100 mg / dl (5.6 mmol / l) six weeks later -Diabetes from it again, "said her family doctor. The diabetes had arisen because of the stress before and during the operation, but also because of the weight gain in recent years and the lack of exercise.

According to a recent study, 2.1 million people with diabetes are treated in hospital in Germany every year. For many, diabetes is mentioned as a secondary diagnosis. Diabetes must also be treated in the clinic, as increased blood sugar levels make complications such as wound healing disorders, kidney failure or even pneumonia possible or worsen dramatically.

It is also assumed that around 10 percent of all patients who are admitted to the operation and who have diabetes know nothing about it: Most of them have prediabetes (impaired glucose tolerance / sugar utilization).

As a result of the stress, more sugar is formed and released in the liver

Due to the stress that a hospital stay or an operation brings with it, more hormones such as glucagon, adrenaline, cortisol and also cytokines get into the blood and cause an increased release and formation of new sugar in the liver. This increases the risk of complications, especially in the case of seriously ill people with diabetes who are cared for in the intensive care unit. The risk of dying is also increased.

Even people who have not previously had elevated blood sugar levels suddenly have significantly increased levels (over 180 mg / dl or 10.0 mmol / l) and require special therapy and monitoring, as they too are at risk of complications due to stress and hypoglycaemia in the course of operations increases. It is not uncommon for a stress-inducing operation to rediscover diabetes. These patients also require special monitoring and, if necessary, therapy, usually with insulin.

With diabetes in the clinic
  • Statistically speaking, people with diabetes are more than twice as likely to come to the clinic as people without diabetes.
  • Diabetics are on average longer in hospital (by 30 percent), an average of two days (according to a recent study from the USA), which of course increases treatment costs.
  • Diabetics have a higher risk of possible consequences of a surgical procedure.
  • The stress of an operation or even a hospital stay (stress leads to high values!) Increases insulin resistance, i.e. worsens insulin sensitivity.

In order to make the therapy of people with diabetes or prediabetes safer, a hospital stay must be carefully prepared. Particular attention must be paid to medication: oral antidiabetic drugs (sugar tablets, e.g. metformin, SGLT-2 inhibitors, DPP-4 inhibitors, sulfonylureas) and drugs that inhibit blood clotting, help with asthma, or treat heart disease.

For ASA (acetylsalicylic acid), which is taken as a platelet inhibitor after a heart attack or in general for coronary artery disease, it was previously the case that it had to be discontinued six days before the procedure. This no longer applies in principle today: Many surgeons also operate under aspirin. Exceptions are usually neurosurgical operations. However, this should be discussed beforehand with the treating doctor in the hospital or the anesthetist.

Withdraw metformin 48 hours before surgery or contrast agent administration

Metformin must usually be discontinued 48 hours before surgery and contrast agent administration. Emergency surgery is possible with metformin. Sulfonylureas (e.g. Glibenclamide) as they can be effective for up to 50 hours after the last dose. Other oral antidiabetic drugs are usually stopped the evening before the procedure.

Most people with diabetes switch from tablets to insulin before and immediately after surgery. If you are recruited to insulin, short-acting insulin analogues are usually used instead of short-acting human insulins (normal insulins), as they have a shorter effect and are therefore easier to control. If there is already an insulin plan, it will be used. During the operation, especially during major interventions, the insulin is continuously supplied via a perfusor (infusion pump). Blood pressure tablets should be taken as before.

Injecting insulin - this is important

1. Procedure for examinations and short, uncomplicated operations (less than 2 hours)

At z. B. gastric or colonoscopies and other examinations for which you should be sober in the morning, you usually inject half the usual mixed insulin dose or just the basal insulin and possibly a morning swab, i.e. about 10 percent of the total amount of short-acting insulin for the Day. Blood sugar should be checked regularly during the inpatient stay in the hospital.

The basal rate can also be continued unchanged for those who wear insulin pumps. It is corrected by a bolus with a short-acting insulin analog. After the operation - because of the stress - a higher insulin dose may be necessary.

2. Procedure for longer, complicated operations

If the operation takes longer and is complicated (possibly with subsequent care in the intensive care unit), the usual diet and treatment are usually maintained until one day before the operation. The oral antidiabetic drugs are discontinued 1 to 2 days beforehand. Before the operation, the patient stays sober.

In the case of insulin pump therapy, the pump therapy is usually interrupted and the patient usually receives a glucose-insulin-potassium infusion, with blood sugar corrections or the administration of glucose being controlled by regular blood sugar measurements.

When the patient takes his first regular meal again, the subcutaneous administration of insulin is started again beforehand. If a diabetologist is directly available, the pump therapy can be continued as usual.

Which values ​​are to be aimed for?

The goals during short-term hospital treatment, including surgery, are:

  • safe adjustment of the blood sugar level to moderate target values ​​(140 - 180 mg / dl or 7.8 - 10.0 mmol / l),
  • strict avoidance of hypoglycaemia,
  • Initiation of a new diabetes therapy or optimization of an existing treatment.

The recommendation of a blood sugar setting between 140 and 180 mg / dl (7.8 and 10.0 mmol / l) in critically ill patients comes from the American Diabetes Association (ADA) based on numerous studies in patients in intensive care units.

It would also be desirable - especially in the case of older people with diabetes and frequent comorbidities (multimorbidity) - if the patients could be admitted to the hospital 1 to 2 days before the operation in order to ensure adequate anesthesia preparation and e.g. B. to discuss the type of operation and the drug approach - this could reduce the risk.

Since this is not possible (for reasons of cost!), The doctor in charge should contact the treating clinic in advance, if necessary, in order to clarify which form of anesthesia is the right one for the patient, taking into account any existing consequential damage.

Checklist: What do I have to take to the hospital?
  1. Completed Diabetes Health Passport
  2. Data on the onset and course of diabetes
  3. Current medication plan
  4. Name, address and telephone number of the treating diabetologist or general practitioner
  5. List of pre-existing conditions
  6. Stock of common medicines and diabetes accessories

After the operation

After the operation, oral antidiabetic drugs should only be taken again with the next main meal and, as a rule, only when the patients can eat themselves again, can safely tolerate this diet and there are no other contraindications. Your own insulin regimen should be used immediately after the operation, if you eat normally again, and should be adapted to the new situation as the situation progresses.

Note important concomitant illnesses

Since people with diabetes often have comorbidities such as atrial fibrillation or have had thrombosis with pulmonary embolism as they get older, they often take anticoagulant drugs such as Marcumar, factor Xa inhibitors (Xarelto), apixaban (Eliquis) or factor V inhibitors ( Dabigatran). After an operation, these drugs can and should be used again in consultation with the attending physician.

Most of the patients who previously z. B. after a hip or knee operation temporarily received abdominal injections to inhibit coagulation (low molecular weight heparins), today modern anticoagulants get in the form of tablets immediately after the operation. These are taken until the patient is fully mobilized again, i.e. no longer in bed, and the risk of thrombosis is largely normal.

In connection with taking medication, it should be pointed out once again that around 20 to 40 percent of patients with type 2 diabetes develop kidney failure in the course of their illness, which means that drugs are more difficult to break down. In stressful situations such as operations, kidney function can deteriorate dramatically, which is why oral antidiabetic drugs are usually discontinued and replaced with insulin in this situation.

the essentials in brief

In order to minimize the risks in smaller, medium-sized and larger operations, a blood sugar setting close to the normal (140 - 180 mg / dl or 7.8 - 10.0 mmol / l) is useful or necessary during the entire treatment period, as this will result in reduces the risk of complications during and after surgery.

What risk z. B. is caused by anesthesia, must be discussed with the treating anesthetist and, if necessary, with the surgeon. Concomitant illnesses and previous illnesses must be taken into account - and this usually requires close cooperation between the family doctor or the treating diabetologist and the clinic. Follow-up care is also essential as it improves the patient's prognosis.

Close cooperation between all those involved before, during and after the operation or the hospital stay is an urgent requirement: It is always associated with advantages for people with diabetes and reduces the risk in hospital. In particular, severe hypoglycaemia due to too much insulin and strong blood sugar fluctuations should be avoided during an operation, because they worsen the long-term prognosis!

by Dr. Gerhard-W. Schmeisl
Internist / angiologist / diabetologist, chief physician Deegenbergklinik
as well as chief physician diabetology clinic Saale (DRV-Bund)

Deegenberg Clinic, Burgstrasse 21,
97688 Bad Kissingen, Tel .: 09 71/8 21-0, E-Mail: [email protected]

Clinic Saale, Pfaffstrasse 10,
97688 Bad Kissingen, Tel .: 09 71/8 5-01

Published in: Diabetes-Journal, 2016; 65 (1) pages 30-33

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