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Importance of Considering Carbohydrate Content in OTC Medications for Patients on the Ketogenic Diet

For patients with epilepsy on a ketogenic diet, maintaining ketosis is important for seizure control. While these diets are highly effective for some individuals with intractable epilepsy, they require stringent carbohydrate restrictions, and neglecting carbohydrate content from medication and supplements can mean the difference between feasibility and effectiveness or not of the diet for seizure control.

Why It Matters:

Over the counter (OTC) medications, particularly liquid formulations, chewable tablets, and suspensions, often contain significant “hidden” carbohydrates. Even small unaccounted for amounts of carbohydrates can disrupt ketosis, potentially leading to increased seizure activity. If accounted for but not converted to tablet formulations, this will make the diet that much harder, increasing the likelihood that the patient will find it unfeasible. For example, liquid acetaminophen products often contain significantly higher carbohydrate levels than tablet formulations.

Expert Opinion and Recommendations for Healthcare Providers:

 

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Review Inactive Ingredients: 

Assess all medications for carbohydrate content. Common carbohydrate-containing excipients to avoid include:

  • Glycerin
  • Maltodextrin
  • Organic acids (e.g., ascorbic acid, citric acid, lactic acid)
  • Propylene glycol
  • Sugars (e.g., dextrose, fructose, glucose, lactose, sucrose, sugar, palm sugar, cane syrup, cane juice, corn syrup, honey)
  • Sugar alcohols (e.g., erythritol, isomalt, glycerol, mannitol, maltitol, sorbitol, xylitol)
  • Starches (e.g., cornstarch, hydrogenated starch hydrolysates [HSH], pregelatinized starch, sodium starch glycolate)

 

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Advise Patients and Caregivers:

Encourage families to check medication labels carefully and consult with healthcare providers before using any OTC products. Educate them that “sugar-free” does not always mean carbohydrate-free.

 


 

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Coordinate with Pharmacies:

Clearly communicate to outpatient pharmacies that the patient is on a ketogenic diet. Specify carbohydrate-free or low-carbohydrate formulations in prescriptions. 

 


 

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Utilize Resources: 


 

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Provide Education: 

Equip patients and families with the knowledge to safely manage their medication regimens, including identifying carbohydrate-free options and understanding the implications of label ingredients.

 
 

Resources & References

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Carbohydrate content of commonly used medicines:

 

https://www.matthewsfriends.org/wp-content/uploads/2024/05/WEB-KC_ADVANCE_MEDICINE_LIST_2024.pdf 

 

https://ketodietcalculator.org/

 

References arrow_drop_down

Mackenzie C. Cervenka, MD, Sarah Doerrer, CPNP, Bobbie J. Barron, RD, LDN, Eric H. Kossoff, MD, Zahava Turner, RD, CSP, LDN. The Ketogenic and Modified Atkins Diets: Treatments for Epilepsy and Other Disorders, 6th edition. Springer Publishing Company, New York, Mar 21, 2016

 

Borowicz-Reutt, K., Krawczyk, M., & Czernia, J. (2024). Ketogenic Diet in the Treatment of Epilepsy. Nutrients, 16(9), 1258. https://doi.org/10.3390/nu16091258

 

Katz, J. B., Owusu, K., Nussbaum, I., Beekman, R., DeFilippo, N. A., Gilmore, E. J., Hirsch, L. J., Cervenka, M. C., & Maciel, C. B. (2021). Pearls and Pitfalls of Introducing Ketogenic Diet in Adult Status Epilepticus: A Practical Guide for the Intensivist. Journal of Clinical Medicine, 10(4), 881. https://doi.org/10.3390/jcm10040881

 

Cameron, T. Carbohydrate Content of Commonly Used Medicines. Matthew’s Friends KetoCollege. Available online: https://www.matthewsfriends.org/keto-therapies/keto-management/ketogenic-therapy-anti-epileptic-medications/carbohydrate-content-medications/ (accessed on 23 Jan 2025).

 
This information was curated by the AES Treatments Committee to offer providers guidance on approved over-the-counter (OTC) drugs with an emphasis on their use by people with epilepsy. The information presented on this page is designed to be informational for a broad audience and is not medical advice. For personalized recommendations, speak to a pharmacist or healthcare provider.