Low-Carbohydrate Nutrition Approaches in Patients with Obesity, Prediabetes and Type 2 Diabetes

Low Carb Nutrition - Queen's Units

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13 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

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