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British Journal of General Practice

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Clinical Intelligence

Adapting diabetes medication for low carbohydrate management of type 2 diabetes: a practical guide

Campbell Murdoch, David Unwin, David Cavan, Mark Cucuzzella and Mahendra Patel
British Journal of General Practice 2019; 69 (684): 360-361. DOI: https://doi.org/10.3399/bjgp19X704525
Campbell Murdoch
Wincanton Health Centre, Wincanton; chief medical officer, Digital Diabetes Media, Coventry, UK.
Roles: GP
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David Unwin
Norwood Surgery, Southport, UK.
Roles: GP
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David Cavan
London Medical, London, UK.
Roles: Consultant physician and endocrinologist
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Mark Cucuzzella
West Virginia University School of Medicine, WVU Center for Diabetes and Metabolic Health, Morgantown, US.
Roles: Professor
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Mahendra Patel
Medical School, University of Sheffield, Sheffield, UK.
Roles: Senior academic and pharmacist, honorary senior lecturer
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    Box 1.

    Summary guidance on adapting diabetes medication for low carbohydrate management of type 2 diabetes

    Drug groupHypo risk?Clinical suggestion
    Sulphonylureas (for example, gliclazide) and meglitinides (for example, repaglinide)YesReduce/stop (if gradual carbohydrate reduction then wean by halving dose successively)
    InsulinsYesReduce/stop. Typically wean by 30–50% successively. Beware insulin insufficiencya
    SGLT2 inhibitors (flozins)NoKetoacidosis risk if insulin insufficiency. Usually stop in community setting
    Biguanides (metformin)NoOptional, consider clinical pros/cons
    GLP-1 agonists (-enatide/-glutide)NoOptional, consider clinical pros/cons
    Thiazolidinediones (glitazones)NoUsually stop, concerns over long-term risks usually outweigh benefit
    DPP-4 inhibitors (glipitins)NoUsually stop, due to lack of benefit
    Alpha-glucosidase inhibitors (acarbose)NoUsually stop, due to no benefit if low starch/sucrose ingestion
    Self-monitoring blood glucoseN/AEnsure adequate testing supplies for patients on drugs that risk hypoglycaemia. Testing can also support behaviour change (for example, paired pre- and post-meal testing)
    • ↵a Caution should be taken when reducing insulin if there is clinical suspicion of endogenous insulin insufficiency (Patients with LADA misdiagnosed as T2D; a minority of T2 patients have endogenous insulin deficiency). Consider these possibilities if patient was not overweight at diagnosis. Exogenous insulin should not be completely stopped in these cases. Inappropriate over-reduction of exogenous insulin will lead to marked hyperglycaemia. Hypo = hypoglycaemia. LADA = latent autoimmune diabetes in adults. T2D = type 2 diabetes.

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British Journal of General Practice: 69 (684)
British Journal of General Practice
Vol. 69, Issue 684
July 2019
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Adapting diabetes medication for low carbohydrate management of type 2 diabetes: a practical guide
Campbell Murdoch, David Unwin, David Cavan, Mark Cucuzzella, Mahendra Patel
British Journal of General Practice 2019; 69 (684): 360-361. DOI: 10.3399/bjgp19X704525

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Adapting diabetes medication for low carbohydrate management of type 2 diabetes: a practical guide
Campbell Murdoch, David Unwin, David Cavan, Mark Cucuzzella, Mahendra Patel
British Journal of General Practice 2019; 69 (684): 360-361. DOI: 10.3399/bjgp19X704525
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  • Article
    • INTRODUCTION
    • THE LCD IN TYPE 2 DIABETES
    • DIABETES MEDICATIONS AND AN LCD
    • MEDICATIONS THAT CREATE A RISK OF HYPOGLYCAEMIA
    • MEDICATIONS THAT RISK KETOACIDOSIS
    • MEDICATIONS THAT POSE NO EXCESS RISK WITH AN LCD
    • CONCLUSION
    • Notes
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