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

Article Figures & Data

Box 1.

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

Drug group	Hypo risk?	Clinical suggestion
Sulphonylureas (for example, gliclazide) and meglitinides (for example, repaglinide)	Yes	Reduce/stop (if gradual carbohydrate reduction then wean by halving dose successively)
Insulins	Yes	Reduce/stop. Typically wean by 30–50% successively. Beware insulin insufficiency^a
SGLT2 inhibitors (flozins)	No	Ketoacidosis risk if insulin insufficiency. Usually stop in community setting
Biguanides (metformin)	No	Optional, consider clinical pros/cons
GLP-1 agonists (-enatide/-glutide)	No	Optional, consider clinical pros/cons
Thiazolidinediones (glitazones)	No	Usually stop, concerns over long-term risks usually outweigh benefit
DPP-4 inhibitors (glipitins)	No	Usually stop, due to lack of benefit
Alpha-glucosidase inhibitors (acarbose)	No	Usually stop, due to no benefit if low starch/sucrose ingestion
Self-monitoring blood glucose	N/A	Ensure 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.