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A safety checklist for physicians. Review all current medications before initiating dietary carbohydrate restriction.
| Risk | Drug Class | Examples | Risk on Low-Carb Diet | Action Required | Timing | Monitoring |
|---|---|---|---|---|---|---|
| HIGH RISK | Insulin (all types) | Glargine (Lantus, Basaglar), detemir (Levemir), degludec (Tresiba), lispro (Humalog), aspart (NovoLog), regular insulin | Hypoglycaemia. As carbohydrate intake drops, insulin requirements can fall dramatically within 24–72 hours. Patients on fixed insulin doses are at high risk of severe hypoglycaemia. | Reduce basal insulin by 20–50% on day 1. Reduce rapid-acting insulin proportionally to carbohydrate reduction. Provide specific dose adjustment instructions in writing. | Day 1 of dietary change | Check fasting glucose daily for 1 week. Check pre-meal glucose if on rapid-acting insulin. Target fasting glucose 80–130 mg/dL. |
| HIGH RISK | Sulfonylureas | Glipizide (Glucotrol), glimepiride (Amaryl), glyburide (DiaBeta, Micronase), glibenclamide | Hypoglycaemia. Sulfonylureas stimulate insulin secretion regardless of glucose level. On a low-carb diet, this can cause prolonged hypoglycaemia, especially with glyburide (long half-life). | Reduce dose by 50% on day 1. Consider stopping glyburide entirely and switching to glipizide (shorter half-life) if continuing. Many patients can discontinue sulfonylureas within 1–2 weeks. | Day 1 of dietary change | Check fasting glucose daily. Check 2-hour post-meal glucose. Warn patient about hypoglycaemia symptoms: shakiness, sweating, confusion. |
| HIGH RISK | SGLT-2 Inhibitors | Empagliflozin (Jardiance), dapagliflozin (Farxiga), canagliflozin (Invokana), ertugliflozin (Steglatro) | Euglycaemic diabetic ketoacidosis (euDKA). SGLT-2 inhibitors lower the renal threshold for glucose excretion and promote ketogenesis. Combined with a ketogenic diet, they can precipitate DKA even with normal or near-normal glucose levels. | Discuss risk-benefit carefully. Consider holding SGLT-2 inhibitor for 3–5 days before starting ketogenic diet. If continuing, educate patient on DKA symptoms and ensure they know to check ketones if unwell. | 3–5 days before dietary change | Educate on DKA symptoms: nausea, vomiting, abdominal pain, shortness of breath, fruity breath. Check urine or blood ketones if symptomatic. Check glucose AND ketones - euDKA has normal glucose. |
| MODERATE | Meglitinides | Repaglinide (Prandin), nateglinide (Starlix) | Hypoglycaemia. Similar mechanism to sulfonylureas - stimulate insulin secretion. Risk is lower due to shorter half-life and meal-dependent dosing. | Reduce dose by 50% or discontinue if patient is significantly reducing carbohydrate intake. These drugs are designed for post-meal glucose spikes, which will be minimal on a low-carb diet. | Day 1 of dietary change | Check post-meal glucose. Many patients can discontinue meglitinides within 1–2 weeks. |
| MODERATE | Antihypertensives (diuretics) | Hydrochlorothiazide (HCTZ), chlorthalidone, furosemide (Lasix), spironolactone, amiloride | Hypotension and electrolyte imbalance. A low-carbohydrate diet causes rapid natriuresis (sodium excretion) as insulin levels fall. Combined with diuretics, this can cause significant dehydration, hypotension, and electrolyte disturbances. | Reduce or hold diuretic dose at initiation. Monitor blood pressure closely. Ensure adequate sodium and fluid intake. Thiazide diuretics also worsen insulin resistance - discontinuation may be appropriate long-term. | Day 1 of dietary change | Check blood pressure at 1 week and 2 weeks. Check electrolytes (sodium, potassium, magnesium) at 2 weeks. Warn patient about orthostatic hypotension symptoms. |
| MODERATE | ACE Inhibitors / ARBs | Lisinopril, enalapril, ramipril (ACEi); losartan, valsartan, irbesartan (ARBs) | Hypotension. Blood pressure can fall significantly with dietary carbohydrate restriction, particularly in the first 2–4 weeks. Also: ACEi/ARBs raise potassium - monitor if supplementing potassium for electrolyte replacement. | Monitor blood pressure weekly for first month. Reduce dose if systolic BP falls below 110 mmHg or patient is symptomatic. Avoid potassium supplementation without monitoring if on ACEi/ARB. | Week 1–4 | Weekly blood pressure for 4 weeks. Check potassium at 2 weeks if patient is supplementing electrolytes. |
| LOW RISK | Metformin | Metformin (Glucophage, Fortamet, Glumetza), metformin XR | Low risk of hypoglycaemia (does not stimulate insulin secretion). However, GI side effects (nausea, diarrhoea) may worsen during dietary transition. Rare risk of lactic acidosis if patient is dehydrated. | Continue at current dose. Ensure adequate hydration. GI side effects often improve with dietary change. Consider dose reduction if patient achieves remission (HbA1c < 6.5% without medication). | Ongoing - reassess at 3 months | HbA1c at 3 months. If remission achieved, discuss stepwise discontinuation with patient. |
| LOW RISK | GLP-1 Receptor Agonists | Semaglutide (Ozempic, Wegovy), liraglutide (Victoza, Saxenda), dulaglutide (Trulicity), exenatide (Byetta) | Low risk of hypoglycaemia in isolation. GI side effects (nausea, vomiting) may compound dietary transition symptoms. Significant appetite suppression - patients may under-eat protein and fat. | Continue at current dose. Counsel patient to prioritise protein and fat intake despite reduced appetite. Monitor for adequate nutrition. Consider dose reduction if patient is losing weight rapidly. | Ongoing - reassess at 3 months | Weight, muscle mass, and nutritional adequacy at 1 month. Ensure patient is eating sufficient protein (≥ 1.2 g/kg body weight). |
| LOW RISK | DPP-4 Inhibitors | Sitagliptin (Januvia), saxagliptin (Onglyza), linagliptin (Tradjenta), alogliptin (Nesina) | Very low risk of hypoglycaemia. Glucose-dependent mechanism. No significant interaction with low-carbohydrate diet. | Continue at current dose. Reassess need at 3 months - many patients achieve glucose control through diet alone and can discontinue. | Reassess at 3 months | HbA1c and fasting glucose at 3 months. |
| MODERATE | Warfarin / Anticoagulants | Warfarin (Coumadin), acenocoumarol | Dietary changes can significantly alter INR. Increased intake of vitamin K-rich vegetables (leafy greens) can reduce warfarin effect. Rapid weight loss can also affect warfarin metabolism. | Check INR within 1–2 weeks of dietary change. Counsel patient to maintain consistent vegetable intake rather than dramatically increasing leafy greens. | 1–2 weeks after dietary change | INR at 1 week and 2 weeks. Adjust warfarin dose as needed. |
| Timepoint | Checks Required |
|---|---|
| Before starting | Fasting glucose · Fasting insulin · HbA1c · Full lipid panel · eGFR · Electrolytes (Na, K, Mg) · Blood pressure · Weight and waist circumference |
| Day 3–5 | Fasting glucose (if on insulin or sulfonylurea) · Blood pressure (if on antihypertensives) · Symptoms check: hypoglycaemia, hypotension, DKA |
| Week 2 | Fasting glucose · Blood pressure · Electrolytes (if on diuretics or ACEi/ARB) · INR (if on warfarin) · Medication dose review |
| Month 1 | Fasting glucose and insulin · Blood pressure · Weight · Medication dose review · Symptom and adherence check |
| Month 3 | HbA1c · Full lipid panel · Fasting insulin and HOMA-IR · eGFR and UACR · Liver enzymes (ALT, GGT) · Uric acid · Full medication review - consider discontinuation |