Diabetes management in people undergoing metabolic-bariatric surgery: A guideline from the Joint British Diabetes Societies for Inpatient Care (JBDS-IP) Group

The global prevalence of obesity and diabetes continues to rise, with metabolic-bariatric surgery recognised as an effective intervention for obesity and type 2 diabetes, offering potential for type 2 diabetes remission and improved glycaemic control. This guideline, developed by the Joint British Diabetes Societies for Inpatient Care (JBDS-IP), provides recommendations for the management of diabetes in individuals undergoing metabolic-bariatric surgery. It emphasises the importance of multidisciplinary care and individualised treatment plans to optimise outcomes. Key recommendations include pre-operative glycaemic optimisation, targeting HbA1c <69 mmol/mol (<8.5%) where safe to do so, prevention of hypoglycaemia throughout all phases of care and providing a framework for medication adjustments during the liver reduction diet (LRD), peri-operative and post-operative phases. For type 2 diabetes, oral and non-insulin therapies such as metformin, DPP4 inhibitors and GLP-1 based therapies may be continued during LRD, while sulfonylureas, meglitinides and SGLT2 inhibitors should be discontinued to reduce the risk of hypoglycaemia. For those with type 2 diabetes on insulin, doses should be reduced by 35%-50% during LRD and adjusted post-operatively based on individual glycaemic control. To prevent diabetic ketoacidosis (DKA) in those with type 1 diabetes, insulin must never be stopped and careful planning with diabetes teams is essential. Post-operatively, regular glucose monitoring, hypoglycaemia surveillance, medication adjustments, and follow-up with diabetes specialists are recommended. This document serves as a guide for clinicians and service commissioners, aiming to improve inpatient diabetes care and outcomes for individuals undergoing metabolic-bariatric surgery.