Article Figures & Data
Tables
- TABLE 1
Half-lives of noninsulin glucose-lowering medications and potential adverse effects relevant in the perioperative period
Medication Half-lifea Adverse effects Metformin 4–9 hours Lactic acidosis (rare) Sulfonylureas Hypoglycemia Glipizide intermediate release 2–5 hours Glimepiride 5–9 hours Glyburide ~10 hours Meglitinides Hypoglycemia Repaglinide ~1 hour Nateglinide ~1.5 hours Thiazolidinediones Fluid retention Pioglitazone 3–7 hours Alpha-glucosidase inhibitors Flatulence, diarrhea, abdominal pain Acarbose ~2 hours Dipeptidyl peptidase 4 inhibitors Alogliptin ~21 hours Linagliptin 12 hours Sitagliptin ~12.4 hours Saxagliptin ~2.5 hours Sodium-glucose cotransporter 2 inhibitors Volume depletion, hypotension, diabetic ketoacidosis (euglycemic diabetic ketoacidosis) Canagliflozin 10–13 hours Dapagliflozin ~12.9 hours Empagliflozin ~12.4 hours Bexagliflozin ~12 hours Ertugliflozin ~16.6 hours Glucagon-like peptide-1 receptor agonists, daily administration formulations Nausea, vomiting, delayed gastric emptying Exenatide 2.4 hours Liraglutide 13 hours Oral semaglutide 7 days Glucagon-like peptide-1 receptor agonists, weekly subcutaneous injection formulations Nausea, vomiting, delayed gastric emptying Dulaglutide 5 days Semaglutide 7 days Dual glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 receptor agonist Nausea, vomiting, delayed gastric emptying Tirzepatide 5 days ↵aUpToDate Lexidrug. Wolters Kluwer. http://online.lexi.com. Accessed June 13, 2025.
- TABLE 2
Medical society recommendations on adjusting noninsulin glucose-lowering medications before surgical procedures
Medication ADA (2024)3 CPOC (2023)4 AAGBI (2019)5 SAMBA (2024)2 Metformin Hold day of surgery am surgery or pm surgery: if taken once or twice a day, take as normal; if taken 3 times daily, omit lunchtime dose
Hold if acute kidney injury or eGFR < 30 mL/min/1.73 m2
Omit day of surgery and for 48 hours after if contrast dye will be used or eGFR < 60 mL/min/1.73 m2Take as normal day of surgerya
Omit on day of surgery and for 48 hours after if contrast dye will be used or eGFR < 60 mL/min/1.73 m2Take day of surgery unless eGFR < 45 mL/min/1.73 m2 or procedure includes nephrotoxic agents (eg, contrast dye)c Sulfonylureas Hold morning of surgeryb am surgery: omit on morning of surgery; if taken twice daily, take evening dose if eating
pm surgery: do not take on day of surgeryam surgery: omit if taken once daily (morning); if taken twice daily, omit morning dosea
pm surgery: omit if taken once daily (morning); if taken twice daily, omit both dosesaHold day of surgeryc Meglitinides Hold morning of surgeryb For am surgery, omit morning dose if not eating; for pm surgery, give morning dose if eating For am surgery, omit morning dose if not eatinga; for pm surgery, give morning dose if eatinga Hold day of surgeryc Thiazolidinediones Hold morning of surgeryb Take as normal on day of surgery Take as normal day of surgerya Take day of surgeryc Alpha-glucosidase inhibitors Hold morning of surgeryb For AM surgery, omit morning dose if not eating; for PM surgery, give morning dose if eating For AM surgery, omit morning dose if not eatinga; for PM surgery, give morning dose if eatinga Hold for morning surgery (may take if patient eats morning meal)c DPP-4 inhibitors Hold morning of surgeryb Take as normal day of surgery Take as normal day of surgerya Take day of surgeryc SGLT-2 inhibitors Hold 3–4 days before surgery Omit day before surgery and day of surgeryd Do not take day of surgeryae Hold 3 days before surgery (hold ertugliflozin 4 days before)c GLP-1 receptor agonists, daily and weekly formulations No specific recommendationf Take as normal day of surgeryg Take as normal day of surgerya Hold daily formulations day of surgeryc and weekly formulations a week before surgerych Dual GIP and GLP-1 receptor agonist No specific recommendation No specific recommendation No specific recommendation Take day of surgery (may hold if patient often has nausea or vomiting after taking or is at high risk for postoperative nausea and vomiting)ch ↵aGuideline for short starvation period: no more than 1 missed meal.
↵bThe ADA gives specific recommendations for metformin and SGLT-2 inhibitors and advises holding other oral glucose-lowering drugs the morning of surgery or procedure.
↵cGuidelines for patients undergoing ambulatory surgery.
↵dCheck blood ketones daily if patient with diabetes is normally on SGLT-2 inhibitors even if glucose concentrations are normal.
↵eIf oral intake will decrease before a procedure, stop the drug the day intake is reduced.
↵fData on the safe use and effects of GLP-1 receptor agonists on glycemia and gastric emptying during the perioperative period are limited.
↵gThese drugs should be continued for perioperative glycemic control, but precautions are needed to prevent pulmonary aspiration.
↵hThe American Society of Anesthesiologists recommends considering holding weekly dosing GLP-1 agonists a week before the procedure or surgery.10
AAGBI = Association of Anaesthetists of Great Britain and Ireland; ADA = American Diabetes Association; CPOC = Centre for Perioperative Care; DPP-4 = dipeptidyl peptidase 4 inhibitors; GIP = glucose-dependent insulinotropic polypeptide; GLP-1 = glucagon-like peptide 1; eGFR = estimated glomerular filtration rate; SAMBA = Society for Ambulatory Anesthesia; SGLT-2 = sodium-glucose cotransporter 2
- TABLE 3
Cleveland Clinic Anesthesiology Institute preoperative medication guidelines for diabetes6
Medication Days before surgery Day of surgery All oral hypoglycemics (except sodium-glucose cotransporter 2 inhibitors) Continue Hold all on day of surgery Sodium-glucose cotransporter 2 inhibitors All except ertugliflozin Hold 3 days preoperatively Hold Ertugliflozin Hold 4 days preoperatively Hold Glucagon-like peptide 1 receptor agonists Oral or daily injectable Continue Hold Weekly injectable Hold the dose the week before surgery Hold Note: Guidelines revised October 2023. Regimens can be adjusted based on clinical judgment and on individual patient basis.
