International Recommendations for the Management of Adults Treated With Ketogenic Diet Therapies

Abstract

Objective:To evaluate current clinical practices and evidence-based literature to establish preliminary recommendations for the management of adults using ketogenic diet therapies (KDTs).Methods:A 12-topic survey was distributed to international experts on KDTs in adults consisting of neurologists and dietitians at medical institutions providing KDTs to adults with epilepsy and other neurologic disorders. Panel survey responses were tabulated by the authors to determine the common and disparate practices between institutions and to compare these practices in adults to KDT recommendations in children and the medical literature. Recommendations are based on a combination of clinical evidence and expert opinion regarding management of KDTs.Results:Surveys were obtained from 20 medical institutions with >2000 adult patients treated with KDTs for epilepsy or other neurologic disorders. Common side effects reported are similar to those observed in children and recommendations for management are comparable with important distinctions, which are emphasized. Institutions differ with regard to recommended biochemical assessment, screening, monitoring, and concern for long-term side effects and further investigation is warranted to determine the optimal clinical management. Differences also exist between screening and monitoring practices among adult and pediatric providers.Conclusions:KDTs may be safe and effective in treating adults with drug-resistant epilepsy and there is emerging evidence supporting the use in other adult neurologic disorders and general medical conditions as well. Therefore, expert recommendations to guide optimal care are critical as well as further evidence-based investigation.

Cross‐tissue immune profiling of APOE ε4 reveals early dysregulation in Alzheimer's disease

“…Medical ketogenic diets, focused on increasingly quality fat intake and reducing carbohydrate consumption to promote production of ketone bodies are widely regarded as a gold‐standard systemic anti‐inflammatory diet 16 . They have demonstrated treatment benefits for epilepsy, general neurological conditions including AD, and cancers 15,39–41 . The intervention increased serum β‐hydroxybutyrate in both groups, confirming ketone body induction (Table S13).…”

“…16 They have demonstrated treatment benefits for epilepsy, general neurological conditions including AD, and cancers. 15,[39][40][41] The intervention increased serum β-hydroxybutyrate in both groups, confirming ketone body induction (Table S13).…”

Cross‐tissue immune profiling of APOE ε4 reveals early dysregulation in Alzheimer's disease

“…Medical ketogenic diets, focused on increasingly quality fat intake and reducing carbohydrate consumption to promote production of ketone bodies are widely regarded as a gold‐standard systemic anti‐inflammatory diet 16 . They have demonstrated treatment benefits for epilepsy, general neurological conditions including AD, and cancers 15,39–41 . The intervention increased serum β‐hydroxybutyrate in both groups, confirming ketone body induction (Table S13).…”

“…16 They have demonstrated treatment benefits for epilepsy, general neurological conditions including AD, and cancers. 15,[39][40][41] The intervention increased serum β-hydroxybutyrate in both groups, confirming ketone body induction (Table S13).…”

Clinical Insights Into the Mechanistic Crossroads of Lamotrigine and Therapeutic Ketosis in Bipolar Depression

“…A study assessing plasma-free carnitine levels in patients with epilepsy treated with anticonvulsants, with or without KD, found no hypocarnitinemia in LTG-treated patients, whereas carnitine deficiency was linked to VPA ( 29 ). While KD nutritional deficiencies have been effectively managed in patients with epilepsy through appropriate supplementation, further investigation is needed on its long-term safety in high-risk groups, including pregnant individuals and those with cardiovascular or renal comorbidities ( 124 ). Additionally, the carbohydrate content of pharmacotherapy may influence maintaining ketosis.…”

Classical and Modified Ketogenic Diets for Children and Young People With Drug‐Resistant Epilepsy: A Reflection of International Dietetic Practice and Best Practice Recommendations for Dietitians

“…This includes testing serum acylcarnitine profile and/or urine organic acids or serum amino acids [ 9 ]. There is currently no definitive consensus regarding the use of KDT during pregnancy [ 16 ]. Adolescent females of child‐bearing age should be advised to exercise caution and, where pregnancy is confirmed or planned, the decision to initiate or continue KDT should be based on a careful risk‐benefit assessment.…”

Cross‐tissue immune profiling of APOE ε4 reveals early dysregulation in Alzheimer's disease

“…Medical ketogenic diets, focused on increasingly quality fat intake and reducing carbohydrate consumption to promote production of ketone bodies are widely regarded as a gold‐standard systemic anti‐inflammatory diet 16 . They have demonstrated treatment benefits for epilepsy, general neurological conditions including AD, and cancers 15,39–41 . The intervention increased serum β‐hydroxybutyrate in both groups, confirming ketone body induction (Table S13).…”

“…16 They have demonstrated treatment benefits for epilepsy, general neurological conditions including AD, and cancers. 15,[39][40][41] The intervention increased serum β-hydroxybutyrate in both groups, confirming ketone body induction (Table S13).…”

Clinical Insights Into the Mechanistic Crossroads of Lamotrigine and Therapeutic Ketosis in Bipolar Depression

“…A study assessing plasma-free carnitine levels in patients with epilepsy treated with anticonvulsants, with or without KD, found no hypocarnitinemia in LTG-treated patients, whereas carnitine deficiency was linked to VPA ( 29 ). While KD nutritional deficiencies have been effectively managed in patients with epilepsy through appropriate supplementation, further investigation is needed on its long-term safety in high-risk groups, including pregnant individuals and those with cardiovascular or renal comorbidities ( 124 ). Additionally, the carbohydrate content of pharmacotherapy may influence maintaining ketosis.…”

Classical and Modified Ketogenic Diets for Children and Young People With Drug‐Resistant Epilepsy: A Reflection of International Dietetic Practice and Best Practice Recommendations for Dietitians

“…This includes testing serum acylcarnitine profile and/or urine organic acids or serum amino acids [ 9 ]. There is currently no definitive consensus regarding the use of KDT during pregnancy [ 16 ]. Adolescent females of child‐bearing age should be advised to exercise caution and, where pregnancy is confirmed or planned, the decision to initiate or continue KDT should be based on a careful risk‐benefit assessment.…”

Cross‐tissue immune profiling of APOE ε4 reveals early dysregulation in Alzheimer's disease

“…Medical ketogenic diets, focused on increasingly quality fat intake and reducing carbohydrate consumption to promote production of ketone bodies are widely regarded as a gold‐standard systemic anti‐inflammatory diet 16 . They have demonstrated treatment benefits for epilepsy, general neurological conditions including AD, and cancers 15,39–41 . The intervention increased serum β‐hydroxybutyrate in both groups, confirming ketone body induction (Table S13).…”

“…16 They have demonstrated treatment benefits for epilepsy, general neurological conditions including AD, and cancers. 15,[39][40][41] The intervention increased serum β-hydroxybutyrate in both groups, confirming ketone body induction (Table S13).…”

Clinical Insights Into the Mechanistic Crossroads of Lamotrigine and Therapeutic Ketosis in Bipolar Depression

“…A study assessing plasma-free carnitine levels in patients with epilepsy treated with anticonvulsants, with or without KD, found no hypocarnitinemia in LTG-treated patients, whereas carnitine deficiency was linked to VPA ( 29 ). While KD nutritional deficiencies have been effectively managed in patients with epilepsy through appropriate supplementation, further investigation is needed on its long-term safety in high-risk groups, including pregnant individuals and those with cardiovascular or renal comorbidities ( 124 ). Additionally, the carbohydrate content of pharmacotherapy may influence maintaining ketosis.…”

Classical and Modified Ketogenic Diets for Children and Young People With Drug‐Resistant Epilepsy: A Reflection of International Dietetic Practice and Best Practice Recommendations for Dietitians

“…This includes testing serum acylcarnitine profile and/or urine organic acids or serum amino acids [ 9 ]. There is currently no definitive consensus regarding the use of KDT during pregnancy [ 16 ]. Adolescent females of child‐bearing age should be advised to exercise caution and, where pregnancy is confirmed or planned, the decision to initiate or continue KDT should be based on a careful risk‐benefit assessment.…”