*4.4.1 Metformin*

We recommend continuing metformin with no dose adjustments when starting TCR because it does not cause hypoglycemia.


#### **Table 2.**

*A summary of low carbohydrate diet and diabetic medication changes.*

*Treating Type 2 Diabetes with Therapeutic Carbohydrate Restriction DOI: http://dx.doi.org/10.5772/intechopen.107184*

#### *4.4.2 Insulin*

Insulin, as the most potent glucose-lowering medication, should be adjusted first. When starting TCR, we should discontinue the use of short-acting insulin given before meals. The patients will likely not require the pre-meal, short-acting insulin because their meals are now much lower in carbohydrates. You can reintroduce shortacting insulin if their postprandial glucose levels are consistently above 200 mg/dL (11 mmol/L) despite TCR compliance.

Patients should also cut back on their long-acting insulin. If the patient is more concerned about hypoglycemic episodes, the long-acting insulin should be reduced by half when TCR begins. It should be reduced by one-third if they are more concerned with strict glucose control. This, however, assumes that their fasting blood glucose is less than 200 mg/dL (11 mmol/L) and that they have had adequate control. If their blood sugars are poorly controlled, and their lowest recent fasting glucose is greater than 200 mg/dL (11 mmol/L), hold off on lowering the long-acting insulin until their blood sugars improve. Finally, mixed insulins, which are a mix of long and shortacting insulins, are difficult to adjust accurately and should be avoided entirely. Only long-acting insulin should be given to the patient.

The one caveat to lowering insulin dosage is that we must be aware of adults with latent autoimmune diabetes (LADA). Although uncommon, these people are more insulin-dependent and will not be able to reduce or stop their dose as quickly or completely as others. TCR is still beneficial for them, but it should be done with caution and at a slower pace when reducing medication dosages. LADA should be considered if someone has a history of DKA or hospitalizations for severe hyperglycemia.

#### *4.4.3 Sulfonylureas*

We recommend stopping sulfonylureas when starting TCR because they can cause significant hypoglycemia. Continue sulfonylureas until sugars are below 200 mg/dL (11 mmol/L) if someone has poorly controlled sugars at baseline, with fasting glucose above 200 mg/dL (11 mmol/L).

#### *4.4.4 GLP-1 agonists and DPP-4 inhibitors*

These can also be continued until excellent glucose control is shown. We can then cut their doses in half to completely stop them once their blood sugars are under control.

### *4.4.5 Inhibitors of SGLT-2*

These medications are beneficial for people with diabetes because they have been shown to reduce cardiovascular mortality. However, they have been linked to an increased risk of DKA, which could be amplified if you are on a carbohydraterestricted diet. SGLT-2 inhibitors, in particular, increase the risk of euglycemic ketoacidosis, which occurs when blood glucose remains normal despite significantly elevated ketones, to the point where the blood becomes dangerously acidic. As a result, if we aren't looking for it specifically, we may miss it. Check a beta-hydroxybutyrate level as well as a metabolic panel for acid–base status if you suspect euglycemic DKA. Because of this risk, we advise all patients starting TCR to stop taking SGLT-2 inhibitors one or two days before reducing carbohydrate intake.
