Practice Perfect 911
The Pod Periop Medical Management Series #5: Diabetic Medications – Keeping It Sweet So You Don’t Go Sour

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Jarrod Shapiro, DPM, FACFAS, FACPM

Practice Perfect May 7, 2024

Welcome back to our continued series on perioperative medication management for the podiatrist. Today, we’re going to talk about medications related to diabetes. This field of medicine has been changing quite a bit recently, so an update is in order.

Let’s start with a quick discussion about safe glucose levels for elective surgery, and then we’ll do a high-yield review of the medications themselves.

Cellular, Acellular and Matrix-like Products (CAMPS) Consensus Document

Windy Cole, DPM, CWSP

Director of Wound Care Research
Kent State University College of Podiatric Medicine
Kent, OH

The purpose of this lecture is to improve the understanding of current biological technologies (CAMPs) used in the repair and regeneration of tissue as part of an evidence-based wound management treatment plan.

Available Credits: CPME 0.5

What’s a safe blood sugar level when doing elective surgery?
The easy answer is “the lower the better.” So, a glycosylated hemoglobin as close to normal is best. However, just being diabetic does not preclude a patient from having elective surgery (especially if that elective surgery is meant to decrease the risk of or treat ulcers). The available research has looked primarily at wound healing and skin and skin structure infections (SSI). A full discussion of this is outside the scope of this editorial, but highlighting a couple of representative studies show that, as the hemoglobin A1c rises, especially above 7.5-8%, the risk of infection increasingly rises. Domek, et al found a 5% increase in complication rates with each 1% increase in A1c.¹ Similarly, Jupiter, et al reported an increased risk of SSI above 7.3%.² As a result of these and other research, I use a glycosylated hemoglobin of 8% as a hard cut off for most surgery on diabetics, with a preference of no higher than 7% when possible.

I use a glycosylated hemoglobin (A1c) of 8% as a hard cut off for most surgery on diabetics, with a preference of no higher than 7% when possible.

Diabetic Medication Management in the Perioperative Period
Information below is abstracted from Preiser, et al³ unless indicated otherwise. Additionally, don’t forget that patients with diabetes are at increased risk of cardiovascular complications, so refer to Practice Perfect 910 for a discussion about medications in this class.

^*Note: Brand names included due to common use to allow recognition rather than as advertisement.

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To make a final comment, recent research has shown that patients taking GLP-1 agonists are at an increased risk of perioperative aspiration due to slowed gastric emptying with these medications.⁴ There’s been some controversy, as the quality of evidence is not high, so some organizations still recommend regular fasting guidelines. Given this controversy, it is safe to hold this medication at least a week in advance but to consult with the patient’s medical doctor if there are questions. Clearly, the management of patients with diabetes is not a simple endeavor.

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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