Glucose management may improve COVID-19 outcomes in diabetes
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Proper glucose management can help improve outcomes for individuals with diabetes who are infected with COVID-19, and providers should not deviate from current diabetes treatment, according to a speaker.
“Patients with uncontrolled diabetes ... have an increased risk for severe COVID-19 disease,” Stefan Bornstein, PhD, dean of Transcampus at King’s College London and Technische Universität Dresden, said during a presentation at the virtual World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease. “Adequate management of diabetes is crucial for these patients.”
The CDC and other national health centers estimated that individuals with diabetes have about 50% greater odds of COVID-19 mortality than those without diabetes. Bornstein said there are two possible links to COVID-19 and diabetes. One mechanism is the angiotensin-converting enzyme 2 (ACE2) acts as a receptor for the COVID-19 spike protein. The coronavirus reduces ACE2 expression, causing cellular damage, hyperinflation and respiratory failure. Additionally, the reduced expression could influence pancreatic beta-cell function.
Another possible mechanism is the DPP-IV enzyme, which has been a receptor for the Middle East respiratory syndrome (MERS) coronavirus in past studies. In those studies, antibodies were directed against the DPP-IV inhibited cells. Bornstein said impaired beta-cell function, insulin resistance and hyperglycemia can all lead to severe COVID-19.
“The better we control the blood glucose, the better we can have an improved outcome in our infected patients,” Bornstein said. “We need to have our patients that are not affected yet by COVID and those that are affected by COVID to control blood sugar as best as we can.”
Bornstein discussed a series of recommendations published in The Lancet Diabetes & Endocrinology. Providers in outpatient care should discuss the importance of optimal metabolic control with individuals with diabetes. Current therapy should be optimized, and providers continue established therapy. Telemedicine should be used to allow patients with diabetes to maintain self-containment.
In the hospital and ICU, glucose management is essential in treating individuals with diabetes. Providers should closely monitor plasma glucose, electrolytes, pH and blood ketones. There should also be monitoring for new-onset diabetes.
“We also looked into the medications and came to an agreement that, of course, in the outpatients you can continue and not stop any hypertensive or diabetic treatment if they are not affected by the virus,” Bornstein said. “Also, with mild infection, there is no reason for changing medications.”
For those with severe COVID-19, providers should use caution with administering metformin and SGLT2 inhibitors due to the possibility of dehydration, lactic acidosis and diabetic ketoacidosis. Dehydration should also be monitored with administering GLP-1 receptor agonists, and patients should have adequate fluids and regular meals.
The pandemic and resulting lockdowns have had other adverse effects on individuals with diabetes. Bornstein said those with diabetic foot disease, those with DKA and individuals in need of metabolic and bariatric surgery may not be receiving proper treatment due to reallocation of resources toward COVID-19. There are also concerns regarding a lack of screening for other diseases.
“We do see the collateral damages of closing down some of our elective programs in the hospitals,” Bornstein said. “For cancer it is quite dramatic, 60,000 years may have been lost ... by not discovering, not screening for cancer appropriately, in the next coming years. This is just for the first half of the year. If this goes on for a year, you can extrapolate how difficult this will be.”
Bornstein also warned that sedentary behavior, changing eating patterns and a greater psychological burden resulting from COVID-19 lockdowns may negatively affect glucose control, especially if they continue over a longer period.
Reference:
Bornstein SR, et al. Lancet Diabetes Endocrinol. 2020;doi:10.1016/S2213-8587(20)30152-2.
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Bornstein S. Managing patients with diabetes and COVID-19. Presented at: World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease; Dec. 3-6, 2020 (virtual meeting).
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