Synopsis
Build an exact, indication-aware medicine plan for adults having elective surgery, balancing withdrawal, thrombosis, aspiration, ketoacidosis, hypoglycaemia, hypotension and postoperative organ function at every transition.
- Reconcile every prescribed, injected, over-the-counter and herbal product with indication, formulation, dose and last administration; then record an exact continue, omit, substitute and restart instruction with an owner.
- For elective adults, continue GLP-1 receptor agonists and dual GIP/GLP-1 agonists under the 2025 UK consensus, while assessing drug, patient and procedure aspiration risks and using appropriate mitigation.
- Omit SGLT2 inhibitors the day before and day of the procedure. Stop them when a preoperative very-low-energy liver-reduction diet begins; provide sick-day rules and avoid prolonged starvation.
Key red flags
An SGLT2 inhibitor plus nausea, abdominal pain, tachypnoea, malaise or unexpected acidosis requires blood ketones and acid-base assessment even when glucose is not markedly raised.
Type 1 diabetes must never be left without basal insulin; fasting changes prandial insulin and may require IV insulin, but complete insulin omission risks ketoacidosis.
A patient taking anticoagulant or antiplatelet therapy without a written last-dose and restart plan needs resolution before a procedure where bleeding consequences are significant.
Long-term glucocorticoid use, known adrenal insufficiency, unexplained perioperative hypotension, vomiting, hyponatraemia or hypoglycaemia requires an adrenal replacement assessment.
A GLP-1 or dual GIP/GLP-1 drug can delay gastric emptying; upper-gastrointestinal symptoms alone neither prove nor exclude retained gastric content, so use individual aspiration-risk assessment.
New acute kidney or liver injury, bleeding, ileus, inability to swallow or prolonged starvation invalidates a prewritten postoperative restart date and requires review.
Nausea, abdominal pain, tachypnoea, dehydration or high-anion-gap acidosis during recent SGLT2 exposure requires urgent ketone testing despite a glucose below classic DKA ranges.
Reasoning priorities
Create a trustworthy list with indications, last doses, formulations, interactions and intended perioperative changes.
Discrepancy between patient report, repeat record and supplied medicines must be resolved; uncertainty is clinically significant for insulin, anticoagulants, steroids and weekly injections.
Worked reasoning
An adult using weekly semaglutide and morning empagliflozin for diabetes is scheduled for a planned procedure under general anaesthesia.
- Confirm indications, dose timing, recent GLP-1 escalation and gastrointestinal history, diabetes type and control, renal function, fasting plan, other glucose-lowering therapy and expected missed meals.
- Continue semaglutide under the 2025 UK elective consensus, complete an individual aspiration-risk assessment and agree mitigation rather than assuming that omission for one dosing interval empties the stomach.
- Omit empagliflozin on the day before and day of the procedure, avoid prolonged fasting and provide written sick-day guidance. Because this patient has diabetes and uses an SGLT2 inhibitor, measure capillary blood ketones daily until eating and drinking normally, even when blood glucose is normal.
- Preserve basal insulin using the applicable adult regimen and omit meal-linked secretagogues or rapid insulin only when that meal is missed; use IV insulin selectively when fasting or decompensation requires it.
- After day surgery restart empagliflozin only once eating and drinking normally, usually 24–48 hours; if admitted, also require clinical stability and capillary ketones below 0.6 mmol/L.