When can they be continued
If your patient is stable and eating, and there are no contraindications to the diabetes medications, these can be continued.
When they should be stopped
Diabetes medications should be withheld if your patient is very sick when the risk of side effects (including lactic acidosis) increases. Situations where diabetes medications should be withheld include:
- Sepsis
- Organ dysfunction
eg. acute kidney injury, hepatic impairment, hypoxia, congestive cardiac failure
- Nausea, vomiting or diarrhoea
- Poor oral intake
- Fasting
- Acute myocardial infarction
- Pancreatitis
- Hypoglycemia – sulfonylureas should be ceased immediately
- IV contrast for CT scans – withhold Metformin 24 hours afterwards if eGFR <30ml/min/1.73m2
If glucose levels rise above 10 mmol/L, then insulin should be started.
Insulin treatment may be:
- Temporary, if glucose control on medications is reasonable (HbA1c < 8.0%)
- Long-term if the pre-admission glucose control is poor (HbA1c>9.0%)
See: How to start insulin for guidance on hospital insulin treatment.
When your patient is recovering, and there are no contraindications to diabetes medications, these can be restarted during the hospital admission.
IV contrast and Metformin
Intravenous contrast can induce nephropathy and lactic acidosis. Although this is rare, it is more likely in people with acute or chronic renal impairment. Metformin can increase this risk.
If your patient is taking Metformin, check their renal function:
- If eGFR >30ml/min/1.73m2 and stable:
- Your patient can continue Metformin
- Check creatinine the following morning
- If eGFR =30ml/min/1.73m2, or there is an acute kidney injury:
- Withhold the Metformin 24 hours before the IV contrast load if the imaging is elective
- Withhold the Metformin for 48 hours after the dose is given
- Give IV 0.18 Normal Saline for 24 hours after dose has been given
- Check the creatinine to ensure it is stable before the Metformin is restarted
When to restart the diabetes medications
Aim to restart diabetes medications when there are no contraindications to them.
If the patient was on insulin at the time of the admission, resume their usual regimen & doses if these were effective & well tolerated.
If insulin was commenced this admission, aim to stop it at the time of discharge when their usual medications are recommended, and the illness is resolving.
Insulin should continue after discharge in the following situations:
- New diagnosis of Type 1 Diabetes
- Type 2 Diabetes and any of the following:
- HbA1c is >9.0% or 75 mmol/mol
- Lantus dose is >20 units daily, where the dose may be weaned by the GP
- Their usual diabetes medications are contraindicated
- Patient prefers to continue insulin instead of their usual medications
If in doubt, contact the Toowoomba Hospital Diabetes Team for advice and support.
Contraindications to Diabetes Medications
Metformin
- Acute renal injury or background CKD (eGFR <30ml/min/1.73m2)
- Sepsis
- Organ dysfunction eg. CCF, COPD, hepatic impairment
- Nausea, vomiting, diarrhoea
- Fasting
- IV contrast if eGFR < 30ml/min/1.73m2
Sulfonylureas (Glipizide, Gliclazide, Glimepiride, Glibenclamide)
- Sepsis
- Organ dysfunction eg. AKI, CCF, COPD, hepatic impairment
- Hypoglycaemia
- Fasting
- At risk for hypoglycemia
eg. CKD, hepatic impairment, cardiac disease, age >65 years old
DDP4-inhibitors (Sitagliptin, Linagliptin, Saxagliptin, Vildagliptin)
- Nausea, vomiting, diarrhoea
- Sepsis
- Organ dysfunction eg. AKI, CCF, COPD, hepatic impairment
- Inflammatory bowel disease
GLP-1 agonist (Exenatide, Dulaglutide, Liraglutide)
- Nausea, vomiting, inflammatory bowel disease
- Sepsis
- Organ dysfunction eg. AKI, CCF, COPD, hepatic impairment
- Pancreatitis
- eGFR <30ml/min/1.73m2
SGLT-2 inhibitors (Dapagliflozin, Empagliflozin)
- Preoperative preparation – cease 3 days before surgery
- Fasting
- Nausea, vomiting, inflammatory bowel disease
- Sepsis
- Organ dysfunction eg. AKI, CCF, COPD, hepatic impairment
- Dehydration, hypotension
- Balanitis
- CKD, eGFR <45 ml/min/1.73m2
- Previous Ketoacidosis
Pioglitazone
- Sepsis
- Organ dysfunction eg. CCF, COPD, hepatic impairment
- Oedematous states
- Osteoporosis or fractures
- Macular degeneration
- Co-administration with insulin – increases the risk of oedema