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Table 4. Adapting Diabetes Medication for Low Carbohydrate
Management of Type 2 Diabetes
Drug Group Action
Hypoglycemia
risk? Clinical suggestion
Biguanides
(metformin)
Reduce hepatic
gluconeogenesis.
Reduce peripheral
insulin.
No Optional, consider
clinical pros/cons.
GLP-1 agonists Slow gastric emptying.
Increase satiety. Increase
insulin secretion.
No Optional, consider
clinical pros/cons.
Insulins Exogenous insulin. Yes Reduce/Stop
a
Sulfonylureas Increase pancreatic
insulin secretion.
Yes Stop (if gradual
carbohydrate reduction
then wean by halving dose)
Meglitinides Increase pancreatic
insulin secretion.
No Reduce/Stop (if gradual
carbohydrate reduction
then wean by halving )
SGLT-2 inhibitors Reduce renal glucose
reabsorption, increasing
glucose excretion in the
urine.
No Consider stopping,
especially with significant
carbohydrate restriction.
(SGTL2i's may cause
ketoacidosis, including
with euglycaemia)
iazolidinediones Reduce peripheral
insulin resistance.
No Usually stop, concerns
over long term risks
usually outweigh benefit.
DPP-4 inhibitors Inhibit DPP-4 enzyme,
potentiating GLP-1
effect.
No Usually stop, due to lack
of benefit.
Alpha-glucosidase
inhibitors
Delay digestion of
starch and sucrose.
No Usually stop, due to no
benefit if low starch/
sucrose ingestion.
Self-monitoring
blood glucose
Provide feedback on
blood glucose and
response to food.
N/A Important to be available
for people on drugs that
risk hypoglycaemia. May
be useful also for helping
to understand blood
glucose response.
a
Insulin reduction suggestion: Important to tailor to individual. Usually requires close supervision with
healthcare professional, and if in doubt seek expert input.
T2DM without 'beta cell failure': Usually reduce insulin dosage by approximately 50% (though a 30%
initial reduction may be appropriate for those with a high HbA1c). Monitor for hypoglycemia, with rescue
glucose if required. Continue down-titration of insulin as insulin resistance improves (can take months in
some cases). Goal for most can be to eliminate exogenous insulin.
Caution: Some people diagnosed with T2DM may have significant 'beta cell failure.' Also people with
other forms of pancreatic insufficiency (e.g. LADA) may have been misdiagnosed as T2DM. Consider
these possibilities if patient was not overweight at diagnosis. Inappropriate over-reduction and cessation of
exogenous insulin is avoidable in these cases as they will become hyperglycemic.
Adapted from: Br J of GP July 2019 ; Murdoch C, Unwin D, Cucuzzella M, Patel M, Cavan D
