Increased incidence of COVID-19 in patients with diabetes
The spread of the novel SARS-CoV-2 coronavirus (COVID-19) has reached pandemic proportions and represents a threat for increased morbidity and mortality, which is particularly observed in older persons and in people with co-morbidities such as overt diabetes, obesity and hypertension.
The high incidence of diabetes throughout the world makes this particularly concerning as the COVID-19 pandemic progresses. Emerging data, particularly from China, indicates that patients with diabetes are at high risk for COVID-19 infection. For example, a large observational report including 1099 patients with confirmed COVID-19 infection indicated that 173 people with severe disease suffered from comorbidities including hypertension (23.7%), diabetes mellitus (16.2%), coronary heart diseases (5.8%), and cerebrovascular disease (2.3%). In another study of 140 patients who were admitted to a hospital with COVID-19, 30% had hypertension and 12% had diabetes.
Diabetes increases morbidity and mortality in diabetic patients with COVID-19
Emerging information suggest that individuals with diabetes are at increased risk for complications including death. For example, the most distinctive comorbidities in 32 non-survivors from a group of 52 intensive care unit patients with COVID-19 in a study in China were diabetes (22%) and cerebrovascular disease. Very recently, a summary report from the Chinese Center for Disease Control of 72 314 cases across the country showed an overall fatality rate of 2.3% but this was increased to 10.5% in people with cardiovascular disease and 7.3% and 6%, respectively for people having diabetes or hypertension. These observations are consistent with prior data concerning people with respiratory diseases. For example, mortality rates among persons with diabetes in Hong Kong aged 75 and over from pneumonia exceed mortality rates in this age group due to cardiovascular disease and cancer. Similar evidence of risk among persons with diabetes has been reported for the two earlier COVID infections, severe acute respiratory syndrome (SARS) which began in 2002 and affected more than 8000 persons, mainly and in Asia and the Middle East, and the respiratory syndrome (MERS) in 2012 which affected more than 2000 persons, mainly in Saudi Arabia.
Importance of glycemic control in those with coexistence of COVID-19 infection and diabetes
To date, there have been only limited experimental studies directly addressing the role of hyperglycemia in the pathogenesis and prognosis of viral respiratory diseases. However, it has been shown that elevated blood glucose levels can directly increase glucose concentrations in airway secretion. In vitro exposure of pulmonary epithelial cells to elevated glucose concentrations significantly increased influenza virus infection and replication, suggesting that hyperglycemia may increase viral replication in vivo. Elevated glucose levels may also serve to suppress the anti-viral immune response. These findings are consistent with studies of patients infected with highly pathogenic avian influenza, whereby hyperglycemia was associated with a fatal outcome. Hyperglycemia may also affect pulmonary function such that influenza virus-induced respiratory dysfunction is exacerbated in patients with diabetes. In animal models of disease, diabetes is associated with numerous structural changes to the lung.
Collectively, experimental data support the notion that glycemic control can have beneficial effects on clinical outcomes in patients with coexistent diabetes and viral respiratory diseases such as COVID-19. However, there are a number of challenges that arise with regard to optimal metabolic control. First, it will be important to raise the awareness among those on the front line of the importance of glycemic control in these patients. In this regard, optimal treatment of such patients should involve a multidisciplinary team approach including specialists in emergency medicine, infectious diseases, respiratory function and endocrinology. Further, support from nutritionists and exercise rehabilitation specialists may be required during prolonged periods of hospitalization and recovery. Experience from China describes some of the first patients treated for Covid-19 infection and shows that during their hospital stay, metabolic control was inadequate as defined by fasting and/or glucose levels outside of the reference ranges.
There are, however, several important unknown issues regarding diabetes and COVID-19. It is unclear whether there are differences in the rates and severity of infections in men versus women with diabetes and whether there is a difference in rates of infection and severity of infection in type 1 versus type 2 diabetic patients. Data shows that an increasing number of diabetic patients are cancelling their routine visits to diabetes clinics. This development along with the increased stress associated with social isolation and lack of physical activity provides a fertile ground for worsening glycemic and blood pressure control, further predisposing these vulnerable patients to COVID-19 infections.
Measures to prevent COVID-19
The following measures are suggested for the prevention of this disease in patients with diabetes:
A.Specific Measures in Patients with Diabetes:
a) It is important that people with diabetes maintain good glycemic control, as it might help in reducing the risk of infection and also its severity. More frequent monitoring of blood glucose levels (with use of self-monitoring blood glucose) is required. Good glycemic control may lessen the chances of superadded bacterial pneumonia as well.
b) Patients with diabetes and co-existing heart disease or kidney disease need special care and attempts should be made to stabilize their cardiac/renal status.
c) Attention to nutrition and adequate protein intake is important. Any deficiencies of minerals and vitamins need to be taken care of.
d) Exercise has been shown to improve immunity, though it might be prudent to be careful and avoid crowded places like gyms or swimming pools.
e) It is important to get influenza and pneumonia vaccinations. The latter may decrease the chances of secondary bacterial pneumonia after respiratory viral infection, however, data regarding the present viral epidemic is not available.
B. General Preventive Measures:
a) Thorough handwashing with soap and water should be encouraged since it kills the virus. Use of alcohol-based hand rubs is also useful.
b) There is a need to practice proper respiratory hygiene by covering the mouth and nose with the elbow or a tissue when coughing or sneezing. Touching of the mouth, nose and eyes should be avoided.
c) Contact with an affected person needs to be minimized. Use of recommended face masks is advised if there is a contact with someone with respiratory symptoms.
d) Non-essential travel to major affected areas should be avoided in order to restrict the spread of infection.
C. Measures in Patients of diabetes with COVID 19 infection:
a) In case a person with diabetes develops a fever, cough, runny nose or dyspnea, the appropriate health authority needs to be notified as testing for this disease is available at selected places only.
b) The affected person needs to be isolated for 14 days or till the symptoms resolve (whichever is longer). Country-specific guidelines need to be followed.
c) The majority of patients have a mild form of the disease and can be managed at home. Hydration should be maintained and symptomatic treatment with acetaminophen, steam inhalation etc. can be given.
d) Patients with type 1 diabetes should measure blood glucose and urinary ketones frequently if fever with hyperglycemia occurs. Frequent changes in dosage and correctional bolus may be required to maintain normoglycemia.
e) Anti-hyperglycemic agents that can cause volume depletion or hypoglycemia should be avoided. Dosage of oral anti-diabetic drugs may need to be reduced. Patients should follow sick day guidelines and may need more frequent monitoring of blood glucose and drug adjustment.
f) Hospitalized patients with severe disease need frequent blood glucose monitoring. Oral agents, especially metformin and sodium glucose cotransporter-2 inhibitors need to be stopped.
g) Insulin is the preferred agent for the control of hyperglycemia in hospitalized sick patients.
Better blood glucose management strategies for patients suffering both diabetes and COVID-19 are needed
For the COVID-19 patients with diabetes, tailored therapeutic strategy and optimal goal of glucose control should be formulated based on clinical classification, coexisting comorbidities, age and other risk factors. Blood glucose should be controlled for all patients during hospitalization to monitor the progress of illness and avoid aggravation. For critical cases, early identification and timely reduction of adverse drug reaction (for instance, glucocorticoid-induced hyperglycemia) could prevent worse symptoms. During the 4-week follow-up period after discharge, blood glucose homeostasis should be maintained continuously and patients need to avoid infectious diseases due to a lower immune response. Long-term follow-up is still essential for diabetic patients to reduce diabetes-related complications and mortality.
Actions to be taken:
a) Provide remote medical consultation for the patients who are not advised to go to the hospital during the COVID-19 outbreak.
b) Coordinate with nutritionists and hospital canteens to offer a diabetic diet.
c) Provide indoor exercise instructions.
d) The anxiety levels of in-patients should be evaluated. Psychological intervention should be carried out for patients in need.
e) Free educational videos and e-books on diabetes self-management and COVID-19 prevention should be provided for the public via mobile apps.
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