New Hypoglycemic Agents Require Perioperative Precautions New Hypoglycemic Agents: A Special Presentation

Background: New noninsulin hypoglycemic agents, the incretin and amylin groups, are available to treat patients with type 2 diabetes and inadequate glucose control with the regular routinely used agents, namely metformin or sulfonylurea. Incretin therapies are based on the release of intestinal peptides (glucagon-like peptide 1) in the presence of glucose in the gut which stimulates insulin secretion. The incretin family of drugs includes exenatide, liraglutide, and sitagliptin. They reduce appetite, gastric emptying, and glucagon levels, while increasing insulin biosynthesis, insulin secretion, and proliferation of pancreatic cells. Adverse events include nausea, vomiting, diarrhea, and risk for hypoglycemia when combined with sulfonylurea but not with metformin. Exenatide is given subcutaneously and has a half-life of 1.0 to 2.5 hours. Sitagliptin is given orally and has a 12-hour half-life. Amilyn is a small peptide hormone produced by the pancreatic β-cells along with insulin after a meal. Pramlintide (Symlin®), an analog of amylin, improves glucose control and reduces HbA1c levels. Nausea is the most common side effect. At this point, recommendations on how to handle these drugs in the perioperative period are based on theoretical risks derived from their mechanisms. These are: withhold the day of surgery to avoid hypoglycemia, monitor for hypoglycemia, use aspiration precautions because of the slowing gastric emptying effect, and take precautions to prevent postoperative nausea and vomiting. In the event that the patients take any of these drugs on the day of surgery, they should be monitored closely for hypoglycemia and delayed stomach emptying precautions during induction and awakening. Insulin should be used to control hyperglycemia intraoperatively. (Reviewer-).