Treatment regimens

Oral hypoglycaemic agents are of two types. The sulphonylureas stimulate release of insulin from the pancreatic islets. Chlorpropamide has a very prolonged duration of action and may cause hypoglycaemia unless it is withdrawn 48 h before surgery. A change to a shorter-acting agent such as glipizide or gliclazide is preferable.

Biguanides, which increase peripheral uptake of glucose and decrease gluconeogenesis, are used in obese maturity-onset diabetics either alone or in combination with sulphonylureas. These agents may cause lactic acidosis, usually, but not exclusively, in patients with even mild renal or hepatic impairment. Guidelines for the administration of i.v. contrast media include the instructions to withhold metformin for 24 h before and 48 h after the investigation. Lactic acidosis carries a very high mortality; consequently, metformin, the only biguanide now available, should be discontinued at least 24 h before surgery.

The last dose of oral hypoglycaemic agent should be administered 24 h before surgery and no further treatment is required until the morning of surgery if blood glucose control is satisfactory.

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