Adjusting medications
on a low-carb diet

Carbohydrate restriction in the form of a low-carb diet is effective for lowering blood sugar, improving insulin sensitivity, and reducing blood pressure.¹ However, without careful monitoring, low-carb diets can be victims of their own success, triggering symptomatic hypoglycemia or hypotension. Therefore, clinicians using carbohydrate restriction need to be proactive about preventing these complications.

There are two major classes of medications that often need to be reduced on a low-carb diet: blood glucose-lowering medications and blood pressure medications.

Blood glucose lowering medications

When patients with type 2 diabetes start a low-carb diet, their blood glucose usually goes down immediately and can continue dropping as weight loss continues and insulin resistance improves.²

As this happens, patients on blood glucose-lowering medications may need to reduce their doses and number of medications to avoid hypoglycemia. It’s important for their doctor to know how to handle this situation. Hypoglycemia due to overdosing of blood glucose-lowering medications, especially insulin, is the biggest risk when starting a low-carb diet.³

Slightly high glucose is safer than too low

Although not all patients reducing carbohydrate intake will exhibit an immediate drop in blood glucose, many will see a profound drop on day one.

Because low blood sugar is far more dangerous in the short term, it’s safer to have your patients’ sugars run a little bit higher than the desired range for the initial few days to weeks.⁴

Deprescribing

If your patient is on insulin or a sulfonylurea, you will most likely need to decrease the doses or discontinue medications, initially targeting daily blood glucose levels between 145 to 200 mg/dL (between 8.0 and 11.1 mmol/L).⁵

We recommend assessing the patient’s risk of hypoglycemia in order to determine the magnitude of any dose adjustments. This assessment should include: blood glucose levels, doses of diabetes medications, baseline carbohydrate intake, and age.⁶

For example, if a patient’s blood glucose levels tend to be more than 250 mg/dL (13.9 mmol/L) throughout the day, that might make you less worried that they will experience significant hypoglycemia upon initiation of a low-carb diet. Is that enough to say that no dose adjustments are needed? No, it is not.

Let’s assume that the above patient is achieving that high level of average glycemia while taking 80 units of insulin glargine, 8mg of glimepiride, and 2000mg of extended release metformin daily. Let’s also assume that the person is eating 300 grams of carbohydrate most days. How would that change your assessment of their risk of hypoglycemia?

The high doses of basal insulin and sulfonylurea, combined with the baseline high carbohydrate intake, put this patient at more significant risk of hypoglycemia once the carbohydrate intake is cut to 20-50 grams/day.

If this patient was elderly, the risk of a significant fall during a hypoglycemic episode would push the overall risk to even higher levels.

Although we recommend using clinical judgment in every situation, if the risk of hypoglycemia is moderate to high, we suggest stopping sulfonylureas and short/rapid-acting insulin. We also recommend reducing intermediate/long-acting insulin by 33-50%, again using baseline glycemic control to guide the magnitude of any dose adjustment. It is also important to take into account the patient’s priorities regarding balancing strict glucose control with fear of hypoglycemia.⁷

If, on the other hand, you judge your patient’s risk of hypoglycemia to be low (e.g. baseline blood sugars are extremely high on lower doses of insulin/sulfonylurea), it might be reasonable to hold off on any medication adjustments. We would recommend counseling your patient to monitor blood glucose closely and cut their doses by 50% if levels are falling below 145 mg/dL (8.0 mmol/L), or stop medications completely if they have a hypoglycemic episode.

To summarize, here’s the recommended order of de-prescribing diabetes medications for patients with type 2 diabetes.

1. SGLT-2 inhibitors (due to the risk of ketoacidosis, see below)
2. Short/rapid-acting insulin (risk of hypoglycemia)
3. Intermediate/long-acting insulin (risk of hypoglycemia)
4. Sulfonylureas and meglitinides (risk of hypoglycemia)
5. DPP-4 inhibitors
6. GLP-1 receptor agonists
7. Alpha-glucosidase inhibitors
8. Biguanides (metformin)

You’ll find more details below.

Follow-up adjustments

Within the first few months, blood glucose levels commonly drop back down to an acceptable range. Once the patient’s levels are in the 70-130 mg/dL range (4 to 7.0 mmol/L), it may be time to make medication reductions again, targeting a range of 145 to 200 mg/dL (8.0 to 11.1 mmol/L).⁸

This cycle can repeat itself until the patient is no longer taking diabetes medications (or is only on metformin). After that, the goal is to bring glucose levels down to the normal range utilizing diet alone, targeting a normal HbA1c.⁹

If there is no reduction in blood glucose levels between appointments, no adjustment is necessary. Talk to your patient about their diet. Perhaps there are a few improvements to be made that could speed up the process, but sometimes it just takes a bit longer to see the blood sugar levels come down. If patients are slow to respond to a low-carb diet, put things in perspective by reminding them of how long they have had diabetes and how long it takes to develop.

Sometimes a patient’s blood glucose levels temporarily rise above 200 mg/dL (11.1 mmol/L) for various reasons, such as a vacation, relatives visiting from out of town, illness or infection. If their sugars do not quickly normalize, that patient may need a short-term medication increase. Some patients may be resistant to this, but assure them that it’s only for the short term and the goal is to reduce the dose as soon as is safe.

Reversal of type 2 diabetes¹⁰

It’s not uncommon for patients to reverse their type 2 diabetes on a strict low-carb diet. What does reversal mean? Diet Doctor defines reversal as having a HbA1c measurement below 6.5% without medications except metformin.

The American Diabetes Association changed their definition of remission in 2021. They now consider remission as an HbA1c less than 6.5% (48 mmol/mol) measured at least 3 months after cessation of all diabetes medications.¹¹ We published a video about why this might not be the best definition for individuals to consider.

More about type 2 diabetes medications

A note on SGLT-2 inhibitors

Some doctors choose to have patients stay on SGLT-2 inhibitors and decrease/stop insulin and sulfonylureas first.¹² However, given the multiple case reports of euglycemic ketoacidosis with low- carb diets and SGLT-2 inhibitors, the risks of SGLT-2 inhibitors likely outweigh the benefits.¹³

DPP-4 vs. GLP-1

If your patient is taking both a DPP-4 inhibitor and a GLP-1 receptor agonist, we recommend asking them which medication they would prefer to reduce or discontinue first.

• Some people prefer to discontinue the GLP-1 receptor agonist since it is an injectable and is often considered less convenient due to requiring refrigeration.¹⁵
• However, others find that the GLP-1 receptor agonist reduces appetite, so they prefer to reduce or stop their DPP-4 inhibitor first.

Since neither class of medication puts the patient at significant risk for hypoglycemia, the decision can be made according to the patient’s preference. If the patient has no preference, reduce and discontinue the DPP-4 inhibitor first, as the GLP-1 receptor agonist may decrease hunger and cause some weight loss.

Blood pressure medications

Baseline

Carbohydrate restriction is an effective way to lower blood pressure.¹⁶ However, the change happens more slowly than the change in blood sugar, potentially taking weeks to months. Therefore, you do not have to automatically adjust blood pressure medications as you do with glucose-lowering medications.

Instead, start by making sure your patient is aware of potential symptoms of hypotension (such as lightheadedness, dizziness, fatigue, or nausea) and knows to contact you immediately if they occur.

Follow-up

If the patient presents in clinic with low blood pressure or experiences low blood pressures at home, then you will likely need to reduce or discontinue antihypertensive medications.

Determining which blood pressure medication to discontinue first

There isn’t a universal protocol for which drugs to stop first, as patients have different reasons for being on specific medicines – such as ACE inhibitors for proteinuria, beta blockers for coronary disease, or alpha blockers for benign prostatic hypertrophy (BPH). Thus, we recommend individualizing the de-prescribing of anti-hypertensive medications.

However, if there is no additional indication for a medication, then we recommend stopping diuretics first, since low-carb diets frequently have a diuretic effect of their own.¹⁷

Instruct the patient to continue careful blood pressure monitoring to ensure there is no rebound increase once they reduce or stop their medications.