Adjust diabetes medications while NPO

AS A NUTRITION PHARMACY SPECIALIST, you will be asked how to manage diabetes medications when patients are NPO for NONsurgical reasons. Consider strategies based on the specific medication....

          Insulin or sulfonylureas are the main culprits for hypoglycemia. In general, hold sulfonylureas or MEALTIME insulin once the patient stops eating. For basal insulin, think about reducing the basal dose by about one-third for many patients who are NPO (Nothing by Mouth) for nonsurgical reasons. But consider giving about half the usual dose if the patient's well controlled or at higher risk of hypoglycemia (elderly, kidney impairment, etc). Monitor and adjust insulin as needed for goal blood glucose levels.

Most other diabetes medications rarely cause hypoglycemia. These include metformin (Glucophage), DPP-4 inhibitors [sitagliptin (Januvia), vildagliptin (Galvus), etc), GLP-1 agonists (liraglutide, etc), SGLT2 inhibitors [empagliflozin (Jardiance), etc] and pioglitazone (Actos). If these medications are given at your hospital, generally hold them when patients are made NPO, since NPO order durations can vary. Take extra care to ensure that SGLT2 inhibitors are held in NPO patients. Fasting may increase ketoacidosis risk with these medications. Verify that any inpatient taking a diabetes medications also has a hypoglycemia treatment protocol on their profile.

Note

• When patients are NPO for surgery, use our note, "Preoperative management of diabetes medications in hospitalized patients undergoing surgery",  and "Stopping medications preoperatively in some patients" for guidance on holding and restarting medications, including insulin pumps.
• Get our note, "Manage diabetes medications during fasting", to answer questions about religious and dietary fasts.

REFERENCES

• Grajower MM. 24-Hour Fasting with Diabetes: guide to physicians advising patients on medication adjustments prior to religious observances (or outpatient surgical procedures). Diabetes Metab Res Rev. 2011 Jul;27(5):413-8. Available at: https://onlinelibrary.wiley.com/doi/10.1002/dmrr.1169

  Ibrahim M, Davies MJ, Ahmad E, Annabi FA, Eckel RH, Ba-Essa EM, El Sayed NA, Hess Fischl A, Houeiss P, Iraqi H, Khochtali I, Khunti K, Masood SN, Mimouni-Zerguini S, Shera S, Tuomilehto J, Umpierrez GE. Recommendations for management of diabetes during Ramadan: update 2020, applying the principles of the ADA/EASD consensus. BMJ Open Diabetes Res Care. 2020 May;8(1):e001248. Available at: https://drc.bmj.com/content/8/1/e001248.long

  Grajower MM, Horne BD. Clinical Management of Intermittent Fasting in Patients with Diabetes Mellitus. Nutrients. 2019 Apr 18;11(4):873. Available at: https://www.mdpi.com/2072-6643/11/4/873