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As more people start using low-carb diets to lose weight and improve their health, many people wonder whether their medications will change, too. Unfortunately, there is no way to predict how low-carb diets will affect individual medications for every person. Not all medications have the same effects on the body, and some medications are more sensitive to changes in diet than others.

Reminder: This information is intended for physicians and not for the general public (full disclaimer). Talk to your doctor about any changes in your medications and resulting lifestyle changes.

Carbohydrate restriction in the form of a low-carb diet is effective in lowering blood sugar, reversing diabetes and lowering blood pressure. However, without careful monitoring, low-carb diets can fall victim to their own success and cause symptomatic hypoglycemia or hypotension. Therefore, clinicians who practice carbohydrate restriction should be proactive in preventing these complications.

There are two main categories of medications that often need to be discontinued during a low-carb diet: blood glucose-lowering medications and blood pressure-lowering medications. For more information, see these sections:

Medicines to lower blood sugar levels

When patients with type 2 diabetes begin a low-carbohydrate diet, blood glucose levels usually drop the first day, and may continue to drop as weight loss and insulin resistance improve.

In this case, patients taking glucose-lowering drugs may need to reduce the dose of the drugs to prevent hypoglycemia. It is important that your doctor knows what to do in this situation. Hypoglycemia due to overdose of glucose-lowering drugs, especially insulin, is the greatest risk when starting a low-carb diet.

A slightly higher glucose level is safer than a too low glucose level

It is difficult to predict exactly how your patient’s blood sugar will respond to a reduction in carbohydrate intake. Blood sugar levels usually drop immediately, on the first day, and often several times.

Because of this uncertainty, and because hypoglycemia is much more dangerous in the short term, it is safest to keep your patients’ blood sugar slightly above the desired range for the first few days or weeks.
This avoids the risk of hypoglycemia.

Depreciation

If your patient is on insulin or sulfonylurea – at high risk for hypoglycemia – you should reduce the medication to initially establish a blood glucose target of 145 to 200 mg/dL (8.0 to 11.1 mmol/L). Despite individual differences, it is recommended to discontinue sulfonylurea therapy and short-acting insulin and to reduce the dose of long-acting insulin by 33% to 50% (based on baseline glycemic control, patient desire for tight glycemic control, and fear of hypoglycemia).

Also consider that the more your patient reduces carbohydrate intake, the greater the effect of lowering blood sugar can be. This means that if your patient was eating 300 grams of carbohydrates a day and started eating 20 grams a day, the effect on blood sugar is likely to be very strong.

In summary, the following approach was recommended for prescription cessation in patients with type 2 diabetes.

  1. SGLT-2 inhibitors (because of risk of ketoacidosis, see below)
  2. Long-acting insulin (risk of hypoglycemia)
  3. Fast-acting insulin (risk of hypoglycemia)
  4. sulphonylurea derivatives and meglitinides (risk of hypoglycaemia)
  5. DPP4 inhibitors
  6. GLP-1 agonists
  7. Alphaglucosidase inhibitors
  8. Biguanides (metformin)

For more information, see below.

Subsequent adjustments

During the first few months, the patient’s blood sugar levels usually drop to acceptable levels. When the patient’s levels return to the range of 70-130 mg/dL (4-7.0 mmol/L), it may be time to lower the drug again and aim for the range of 145-200 mg/dL (8.0-11.1 mmol/L).

This cycle can be repeated until the patient is no longer taking diabetes medication (or only metformin). Then the goal is to lower blood sugar to the normal range with diet alone, guided by normal HbA1c levels.

If there is no drop in blood glucose between doses, no adjustment is necessary. Talk to the patient about their diet. You may be able to make some adjustments to speed up the process, but it may take a little longer for your blood sugar to go down. If patients are slow to respond to a low-carbohydrate diet, remind them how long they have had diabetes and how long the disease has existed.

Occasionally, a patient’s blood glucose level may temporarily exceed 200 mg/dL (11.1 mmol/L) for a variety of reasons, including. For example during holidays, when family members come from outside, in case of illness or infection. If sugar levels do not normalize quickly, the patient may need a short-term increase in the medication dose. Some patients may object to this, but reassure them that this is a short-term treatment and the intention is to reduce the dose as soon as it is safe to do so.

Reversal of type 2 diabetes

It is not uncommon for patients to completely get rid of their type 2 diabetes by following a strict low-carb diet. What does the opposite mean? Reversal is defined as an HbA1c measurement of less than 6.5% without medication other than metformin, while remission of diabetes is defined as normoglycemia for at least one year, demonstrated by at least two HbA1c measurements of less than 5.7% and without medication.

Additional information on medication for type 2 diabetes

 

Drugs Mechanism pro and con
SGLT-2 inhibitors

  • Invokana (canagliflozin)
  • Forxiga / Farxiga in the United States (dapagliflozin)
  • Jardiance (empagliflozin)
Inhibits the sodium-glucose co-transporter type 2.

Excretion of glucose in the urine because glucose reabsorption by the kidneys is reduced.

*** RISK OF DIABETIC KETO ACIDOSIS *** especially with a low-carb diet, even if sugar levels are normal. More posts on Invokana medication.

No risk of hypoxia.
The weight does not increase.
It can be assumed that it accelerates the reverse evolution of T2DM.

Long-acting insulin

  • Lantus
  • Levemir
  • Toujeo
  • Tresiba
  • Basaglar
The cells absorb more glucose. High risk of hypoxia.
Increases weight gain.
Aggravates insulin resistance.
Harder to titrate than short-acting drugs.
Short-acting intermediate-acting insulin

  • Humalog
  • NovoRapid
  • Apidra
  • Humulin R
  • Novolin and Toronto
  • Humulin H
  • Novolin ge NPH
The cells absorb more glucose. High risk of hypoxia.
Increases weight gain.
Aggravates insulin resistance.
Easier to titrate than long-acting drugs.
* LA+SA insulin combinations: divided into two categories, long-acting and short-acting, for better titration.
Sulfonylureas and meglitinides

  • Diamicron (gliclazide)
  • Amaryl (glimepiride)
  • Diabetes (Glyburide)
  • Starlix (Nateglinide)
  • GlucoNorm (Repaglinide)
Stimulation of insulin secretion by the pancreas. Risk of hypoxia.
Weight gain.
DPP4 inhibitors

  • Januvia (sitagliptin)
  • Onglyza (saxagliptin)
  • Tragenta (linagliptin)
  • Nesina (alogliptin)
Extend the effect of GLP-1.
Stimulate insulin secretion.
Inhibits the release of glucagon.
No risk of hypoxia.
Not so useful if the patient is not already eating a lot of carbohydrates.
GLP-1 agonists

  • Victoza (liraglutide)
  • Byetta (exenatide)
  • Eperzan (albiglutide)
  • Trulicity (dulaglutide)
Increased insulin production when blood sugar is high.
Reduces glucagon production.
No risk of hypoxia.
Weight loss.
Reduction of appetite, useful in this case.
Alphaglucosidase inhibitors Inhibits the last step of glucose digestion.
Inhibits the conversion of starch into sugar.
Slowing down the absorption of certain types of carbohydrates.
No risk of hypoxia.
The weight does not increase.
Few patients take this drug because it causes intestinal discomfort/diarrhea.
Biguanide

  • Glucophage (metformin)
  • Glumetza (metformin)
Inhibits glucose production in the liver.
Reduces the absorption of glucose by the digestive system.
Increases peripheral glucose absorption.
No risk of hypoxia.
The weight does not increase.

 

Note on SGLT-2 inhibitors

Some physicians prefer that patients continue to use SGLT-2 inhibitors and, if possible, stop insulin and sulfonylurea first. This is because SGLT-2 inhibitors actively remove glucose from the body, lowering insulin levels. Given the numerous reports of euglycemic ketoacidosis with a low-carbohydrate diet and SGLT-2 inhibitors, the risks of SGLT-2 inhibitors likely outweigh the benefits.

If you decide to continue treatment with SGLT-2, ask your patients to watch for the following early symptoms of ketoacidosis They should stop taking the medication and notify you immediately:

  • Nausea
  • Weakness and fatigue
  • Dehydration

However, in most cases and according to the majority of doctors treating low-carb patients, SGLT-2 inhibitors are not worth the risk of ketoacidosis. Therefore, when starting a low-carb diet, the first step is usually to eliminate carbohydrates. This is based on clinical experience.

DPP4 versus GLP-1

Discuss with the patient whether he or she would prefer to lower the dose first and then stop the DDP4 inhibitors or GLP-1 agonists.

  • Some people choose not to take GLP-1 agonists because it is an injectable drug and it is inconvenient to administer because it must be kept refrigerated.
  • However, others find that these injections reduce appetite and prefer to lower the dose of DDP4 inhibitors first.

Since none of these types of drugs expose the patient to the risk of hypoglycemia, the choice depends on the patient’s preference. If the patient does not have a preference, begin tapering and stopping DPP4 inhibitors, as GLP-1 agonists may reduce hunger and cause some weight loss.

Additional equipment

British Journal of General Practice 2018: Adjustment of low-carbohydrate medications in type 2 diabetes: a practical guide

One-page summary for clinicians : Reduction of medication use in type 2 diabetes

Blood pressure medication

Basic level

Limiting carbohydrates is an effective way to lower blood pressure. However, this process is slower than that of blood glucose and may take several days or months. This means that you do not have to automatically adjust your blood pressure medication as is the case with blood glucose lowering medication.

Instead, this can be assessed at follow-up. Start by making sure your patient is aware of possible symptoms of low blood pressure (such as dizziness, fatigue, or nausea) and knows to contact you immediately if they occur.

Overrun of time

If the patient comes to the clinic with low blood pressure or has low blood pressure at home, you will probably need to lower the antihypertensive medication.

Determine which blood pressure medication should be stopped first

There is no universal protocol for which drugs to stop first, because patients may have different reasons for taking certain drugs, for example. B. ACE inhibitors for diabetics, beta blockers for patients with coronary artery disease, or alpha blockers for patients with benign prostatic hypertrophy (BPH). Therefore, we recommend individualizing the prescribing of antihypertensive drugs.

However, unless other drug treatment is required, we recommend stopping diuretics first, as low-carb diets often have a diuretic effect on their own.

Instruct the patient to continue to monitor their blood pressure closely to ensure it does not rise after the medication is reduced or stopped.

Frequently Asked Questions

Can medications affect ketosis?

Medications that affect ketosis include: Antibiotics, such as amoxicillin and ciprofloxacin Anticonvulsants, such as phenytoin and carbamazepine Anti-inflammatory drugs, such as ibuprofen and naproxen Antihistamines, such as diphenhydramine Beta-blockers, such as propranolol and metoprolol Calcium channel blockers, such as nifedipine and verapamil Corticosteroids, such as prednisone Diuretics, such as hydrochlorothiazide and furosemide Hormones, such as estrogen and testosterone Insulin Methyldopa Oral contraceptives, such as ethinyl estradiol and levonorgestrel Phenothiazines, such as chlorpromazine Steroids, such as prednisone and dexamethasone Thyroid medications, such as levothyroxine

How long does it take to adjust to a low carb diet?

It takes a few weeks to adjust to a low carb diet.

How do you stop fatigue on a low carb diet?

Fatigue is a common side effect of low carb diets. Fatigue can be caused by a lack of carbs, but it can also be caused by other factors such as sleep deprivation, stress, or illness. Some people find that they are able to avoid fatigue on low carb diets by taking supplements like B vitamins and magnesium. Others find that they are able to avoid fatigue by eating more protein and fat. Some people find that they are able to avoid fatigue by taking a break from low carb eating for a few days. How do you stop fatigue on a ketogenic diet? Fatigue is a common side effect of ketogenic diets. Some people find that they are able to avoid fatigue on ketogenic diets by taking supplements like B vitamins and magnesium. Some people find that they are able to avoid fatigue by taking a break from ketogenic eating for a few days.

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