Mastering Diabetes: Prevent Hypoglycemia with Smart Medication Adjustments

This article discusses what medications diabetics may need to adjust as they eat better and exercise to control their blood sugar.

Blood sugar levels often improve with a healthier diet and increased physical activity.

Glycemic control is beneficial for diabetics, but it requires careful drug adjustments to avoid complications such as hypoglycemia (low blood sugar) and hypotension (low blood pressure).

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Why Adjustments Are Necessary

• Dietary Changes: Reducing carbohydrate intake or adopting fasting protocols can significantly lower blood sugar levels, potentially leading to hypoglycemia if medication doses remain unchanged.
• Improved Insulin Sensitivity: Regular exercise and improved dietary habits enhance insulin sensitivity, which can reduce the need for certain medications.
• Reduction in Insulin Resistance: As insulin resistance resolves, medications such as diuretics may need adjustment due to changes in fluid balance and blood pressure.

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Preventing Hypoglycemia: Diabetes Medication Adjustments

Certain classes of diabetes medications pose a higher risk of hypoglycemia when dietary changes or fasting reduce blood sugar.

The medications are in their generic names. If you are taking a drug not listed below with the same last-sounding syllable, like glitazone, gliptin, glide, gliflozin, etc., then they may be in the same class.

Check with your doctor or ask me in the comments. Some US brand names are listed but may differ in other countries.

Below is an overview of how these medications may require adjustment.

Medications With Low Risk of Hypoglycemia

1. Biguanides (e.g., metformin):
   • Glucophage, Glucophage XR, Glumetza, and Fortamet are brand names of metformin.
   • Risk: Low
   • Adjustment: None required. Metformin reduces hepatic glucose production and does not typically cause hypoglycemia.
2. Thiazolidinediones (e.g., TZDs or thiazolidinediones like pioglitazone (Actos™) and rosiglitazone (Avandia™) lower blood sugar by depositing them into subcutaneous fat.
   • Risk: Low
   • Adjustment: None required. These drugs enhance insulin sensitivity without directly lowering blood sugar.
3. DPP-4 Inhibitors (e.g., saxagliptin (Onglyza™) and sitagliptin (Januvia™) increase insulin secretion):
   • Risk: Low
   • Adjustment: Can skip fasting days to reduce unnecessary medication use and costs.
4. GLP-1 Receptor Agonists (e.g., dulaglutide, semaglutide):
   • Risk: Low
   • Adjustment: None required for weekly injections.
   • Daily versions like Lixisenatide (Lyxumia™ or Adlyxin™) may be skipped on full fasting days.
   • A daily injection of liraglutide (Victoza™) can be continued because the risk of hypoglycemia is low.
5. SGLT-2 Inhibitors (e.g., dapagliflozin (Farxiga™) empagliflozin (Jardiance™), and canagliflozin (Invokana™) ):
   • Risk: Low
   • Adjustment: Skip on fasting days or drink more water if dehydration concerns you.
6. Alpha-glucosidase inhibitors (e.g., Acarbose (Glucobay™, Precose™, and Prandase™) and Miglitol (Glyset™) delay carbohydrate digestion and result in lower glucose levels. 

• • Risk: Low
  • Adjustment: Skip if the patient is not eating carbohydrates that meal not because of hypoglycemia but because they are unnecessary and save money.

7. Bile acid sequestrants (e.g., Colesevelam (Welchol™ and Cholestagel™) sequester bile and lowers blood glucose and cholesterol absorption.

• • Risk: Low
  • Adjustments: Skip, but the dose would be taken if the primary indication is for lowering cholesterol.

8. Dopamine agonists (e.g., bromocriptine)

• • Risk: Low
  • Adjustments: None

9. Amylomimetics (e.g., pramlintide)

• • Risk: Low
  • Adjustment: Take if the patient is taking prandial insulin

What about Combination Medicines?

Some diabetes medications are combinations of the above, like Metaglip, a combination of glipizide and metformin.

In a drug combination, if one drug can cause hypoglycemia, like glipizide in this case, then it should be skipped because it can cause hypoglycemia even though metformin is OK to take alone.

Medications With Moderate to High Risk of Hypoglycemia

1. Sulfonylureas (e.g., glyburide, glipizide):
   • Long-acting sulfonylureas: glyburide (DiaBeta™, Micronase™, Glynase™, Glynase PresTab™), glipizide (Glucotrol™, GlipiZIDE XL™, Glucotrol XL™), and glimepiride (Amaryl™)
   • Risk: High
   • Adjustment: Skip the dose on fasting days or reduce it to half for partial fasts. Close monitoring is essential.
2. Meglitinides (e.g., Nateglinide [Starlix™] and repaglinide [Prandin™]):
   • Risk: Moderate
   • Adjustment: Skip dose before meals with no carbohydrate content.
3. Basal Insulin
   • Glargine 1%, NPH [Humulin™, Novolin™], Levemir (Detemir™), and Glargine (Basaglar™). 
     • Risk: High
     • Adjustment: Reduce to one-third of the usual dose for controlled patients or by half for uncontrolled patients. Monitor closely.
   • Glargine 3%, degludec
     • Risk: Moderate
     • Adjustment: None initially. Monitor closely and proactively; reduce dose if fasting glucose decreases below a pre-specified number.
4. Prandial Insulin (e.g., insulin lispro (Humalog™, Admelog™, Humalog KwikPen™, Lyumjev™), aspart insulin (Novolog™, Fiasp™, NovoLog FlexPen™, NovoLog PenFill™), and insulin glulisine (Apidra™, Apidra SoloStar™):
   • Risk: High
   • Adjustment: Skip the dose if the meal contains no carbohydrates.
5. Insulin Pumps:
   • Risk: High
   • Adjustment: Based on glucose monitoring, adjust basal rates starting at a 10% reduction and fine-tune. Skip bolus doses for carb-free meals.
6. Combination insulins 70/30, 75/25, 50/50: 

• • Risk: High
  • Adjustment: Skip dose based on the above guidelines for prandial insulin

Prior studies of intermittent fasting on insulin patients decreased the doses by 50% and sometimes 75%. However, there were still some who had hypoglycemia, which is why constant monitoring and supervision are essential.

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Anti-hypertensive Medications and Insulin Resistance Resolution

Improved lifestyle habits can reduce insulin resistance, affecting fluid retention and blood pressure. This often necessitates adjustments to anti-hypertensive medications, particularly:

1. Diuretics (e.g., furosemide (Lasix™) and hydrochlorothiazide):
   • Diuresis (fluid loss) may naturally occur when insulin resistance improves, reducing the need for diuretics.
   • Overuse can lead to dehydration and electrolyte imbalances.
   • Recommendation: Monitor blood pressure closely and reduce diuretic doses as needed.
2. Beta-Blockers:
   • These drugs can mask symptoms of hypoglycemia. As blood sugar levels improve, re-evaluate their use, especially in non-cardiac indications.
3. ACE Inhibitors and ARBs (e.g., lisinopril, losartan):
   • These medications may not require dose adjustments but should be monitored closely for potential hypotension as cardiovascular health improves.

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Steps before Intermittent Fasting

1. Talk to your physician about your plans for intermittent fasting. Some physicians may not agree with the method and may dissuade you from doing it.
2. Check and record your weight and waist circumference for baseline.
3. Know your last glycosylated hemoglobin or HbA1c to know how your blood sugar has been controlled over the past three months.
4. Be familiar with your list of medicines and all the doses.
5. Check your blood sugar in the morning before breakfast and after every meal.
6. Check the blood sugar every 2 hours if on insulin and every 4 hours for someone taking sulfonylureas.
7. Personal continuous glucose monitoring systems like Dexcom® have hypoglycemia alerts. In contrast, Abbott Freestyle Libre System® does not have an alert. These systems allow frequent testing without additional expense or discomfort. 

Medication adjustments may need to be continued the longer you fast. That is why the blood sugars should be recorded. This will help your physicians adjust your diabetes medicines. As weight loss happens, the risk of hypoglycemia increases; therefore, medication adjustments should be made as required.

Recording your blood pressure and heart rate is also a good idea since losing weight will lower your blood pressure. It is possible to be a diet-controlled hypertensive.

Remember to increase fluid intake since water from food is also reduced. Feelings of fatigue and weakness can be from dehydration, and SGLT2 inhibitors, diuretics, and other anti-hypertensive drugs may need to be withheld.

Always talk to your doctor when starting an intermittent fasting program.

Key Recommendations for Safe Medication Adjustments

1. Monitor Blood Sugar and Blood Pressure Regularly:
   • Use a glucometer and blood pressure monitor daily, especially during the initial stages of lifestyle changes.
2. Work With a Healthcare Provider:
   • Medication adjustments should always be supervised by a physician to prevent complications.
3. Educate Yourself About Hypoglycemia Symptoms:
   • Symptoms include dizziness, sweating, confusion, and rapid heartbeat.
   • If suspected, address immediately by consuming fast-acting carbohydrates.
4. Adopt a Stepwise Approach:
   • Gradually adjust diet and exercise intensity to give your body time to adapt, minimizing drastic blood sugar or blood pressure drops.

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Conclusion

Starting a healthier diet and exercise regimen is one of the best ways to manage blood sugar and improve overall health. However, it’s essential to adjust medications carefully to avoid hypoglycemia and other complications.

By monitoring closely, making informed adjustments, and working with a healthcare provider, you can maximize the benefits of your lifestyle changes safely and effectively.

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References

1. Grajower MM, Horne BD. “Clinical Management of Intermittent Fasting in Patients with Diabetes Mellitus.” Nutrients. 2019 Apr 18;11(4):873. doi: 10.3390/nu11040873.
2. American Diabetes Association. “Diabetes Management During Lifestyle Changes.” Diabetes Care Guidelines.
3. Saltiel AR, Olefsky JM. “Inflammatory Mechanisms Linking Obesity and Metabolic Disease.” J Clin Invest. 2017.

Image credit: By BruceBlaus – Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=44805230

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