Managing Diabetes in a COVID World
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Managing Diabetes in a COVID World
Disclosure of Relevant Financial Relationships
I have no relationships to disclose
Objectives • Describe factors that may increase the risk of COVID-19 in diabetic patients • Review management strategies for patients with diabetes • Discuss information and key points to provide patients with diabetes during counseling
Diabetes in America 2020
• One of the most common
medical conditions globally
• Expected to increase even if
the prevalence of obesity
remains stable
• 13% (34 mil) of adults have
diabetes
• 26.8% among those aged 65
years and older
• 35% (88 mil) of adults have
prediabetes
CDC. National Diabetes Statistics Report, 2020. https://www.cdc.gov/diabetes/library/features/diabetes-stat-report.html
Wild S, Roglic G, Green A, et al. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care. 2004; 27:1047-53.
Diabetes Health
Outcomes A 10-Year Perspective
Kazemian P,e t al. Evaluation of the Cascade of Diabetes Care in the United States, 2005-2016. JAMA Intern Med. 2016; 179(10):1376-85.
Diabetes and Infectious Disease
1940’s Vaccinations
Prior to 1940’s
• Approximately 20% of diabetics died of infections
After the 1960s
Insulin and
• Less 6% of diabetics died due to infections
Antibiotics
1960’s
Secrest AM, et al Mortality in Type 1 Diabetes. In: Diabetes in America, 3rd edition. Aug 2018
Casqueiro J, at al. Infections in patients with diabetes mellitus: A review of pathogenesis. Indian J Endocrinol Metab. 2012;16(Suppl 1): s27-36.
• Skin and subcutaneous tissues
• Cellulitis
• Superficial mycoses and onychomycosis
Which • Skin lesions
Infections? • Soft tissues, bones, joints
• Necrotizing fasciitis
• Diabetic foot
• Osteomyelitis
• Urinary Tract infections
• Head and neck
• Periodontal disease
• Malignant otitis externa
Toniolo A, et al. The diabetes pandemic and associated infections: suggestions for clinical microbiology. Reviews in Medical Microbiology. 2019;30:1-17.
Organism Incidence Outcomes
TB Greater Worse
Other fungal/aypical Presumed Presumed
histo,blasto,
coccidiomycosis
Respiratory Gram negative and Greater Worse
Staph pneumonias
Infections
Pneumococcal Not different Worse
pneumonia
Influenza Not different Worse
SARS 2003 ?? Increased mortality
SARS-CoV-2/COVID-19
Peleg AY. Common infections in diabetes: pathogenesis, management and relationship to glycaemic control. Diabetes Metab Res Rev. 2007;23(1):3-13.
Yang JK, et al. Plasma glucose levels and diabetes are independent predictors for mortality and morbidity in patients with SARS. Diabet Med. 2006;23(6):623-8.COVID-19 in Critically Ill Patients -
Seattle Region
• 24 patients from 9 Seattle area hospitals
• ICU admissions
• Positive for SARS-CoV-2
• Mean age 64 years
• 63% male
• 50% fever
• 58% diabetes
Pagan K, et al. Covid-19 in critically ill patients in the Seattle region - case series. N Engl J Med. 2020;382:2012-22.• 1063 patients enrolled
• Hypertension: 50%
• Obesity 45%
ACTT-1 Study • Type 2 diabetes: 30%
• More than half of patients had two or more
chronic conditions
Beigel JH, et al. Remdemsivir for the treatment of COVID-19 - final report. N Engl J Med. 2020:383:1813-26.• 5700 patients COVID-19
• Median age: 63 years
• 60% male Patients
• Hypertension: 56.6%
• Obesity: 41.7%
Hospitalized
• Diabetes: 33.8% in NYC
Richardson et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA. 2020;323(20):2052-59.Are patients with diabetes
more likely to get infected
with COVID-19?Does having diabetes increase chances of
contracting COVID-19 infection?
• Diabetes does not appear to increase
susceptibility of COVID-19, although it may be
more frequent in patients with severe infection
Gangopadhyay KK. Dose having diabetes increase chances of contracting COVID-19 infection? Diabetes Metab Syndr. 2020;14(5):765-66.COVID-19:
Outcomes
According to
Pre-existing
Diabetes
Apicella M, et al. COVID-19 in people with diabetes: understanding the reasons or worse outcomes.
Lancet Diabetes Endocrinol. 2020:8;782-92.Type 1 vs. Type 2:
Is There a Difference in Outcomes?
• Hospitalization
• Belgium study of 2336 patients with Type 1 diabetes showed no
evidence of increased hospitalization
• 5 (0.21%) patients were admitted for COVID-19 treatment
• This rate is comparable to the general population
Vangoitsenhoven R, et al. No Evidence of Increased Hospitalization Rate for COVID-19 in Community-Dwelling Patients With Type 1 Diabetes. Diabetes Care. 2020;43(10):e118-9.Type 1 vs. Type 2:
Is There a Difference in Outcomes?
Morbidity and Mortality
Gregory JM, et al. COVID-19 severity is tripled in the diabetes
Barron E, et al. Associations of type 1 and type 2 diabetes with COVID- community: A Prospective analysis of the pandemic’s impact in type 1
19-related mortality in England: a whole-population study. Lancet and type 2 diabetes. Diabetes Care. Dec 2020: online ahead of print
Diabetes Endocrinol. 2020;8:813-22.Why is
Diabetes a
Risk for
Adverse
Outcomes?
Pugliese G, et al. Is diabetes mellitus a risk factor for COronaVIrus Disease 19 (COVID-19)? Acta Diabetologica. 2020:57;1275-85.Lim S, et al. COVID-19 and diabetes mellitus: from pathophysiology to clinical management. Nat Rev Endocrinol. 2021;17(1):11-30.
COVID-19
and Obesity
SAnchis-Gomar F et al. Obesity and outcomes in COVID-19:
When an epidemic and pandemic collide. Mayo Clin Proc.
2020;95(7):1445-53.The
CORONADO
Study
Cariou B et al. Phenotypic characteristics and prognosis of inpatients with COVID-19 and diabetes: the CORONADO study. Diabetologia. 2020:63(8):1500-15.CDC. National Diabetes Statistics Report, 2020. https://www.cdc.gov/diabetes/library/features/diabetes-stat-report.html
Other Risk
Factors
Holman N et al. Risk factors for COVID-19-related mortality in people with type 1 and type 2 diabetes in England: a population-based cohort. Lancet Diabetes Endocrinol.
2020;8(10);823-33.COVID-19 and Glucose Control
• Outcomes separated by
blood glucose levels
• >180 mg/dL - Poorly controlled
•COVID-19 and Glucose
Control
• 453 patients admitted to Union
Hospital in Wuhan, classified as:
• Normal glucose
• Hyperglycemia (fasting 5.6-6.9 mmol/L,
HbA1c 5.7-6.4%)
• Newly diagnosed diabetes (fasting >7.0
mmol/L, HbA1c >6.5%)
• Known diabetes
Li h, et al. Newly diagnosed diabetes is associated with a higher risk of mortality than known diabetes in hospitalized patients with COVID-19. Diabetes Obes Metab.
2020;22(10):1897-1906.COVID-19 and
Hyperglycemia
Caballero AE et al. COVID-19 in people living with diabetes: An international consensus. J
Diabetes Complications. 2020;34(9):107671Glucose on Admission
• 271 patients hospitalized
patients with COVID-19
• Hyperglycemia was a strong
independent predictor of
mortality
Coppelli A, et al. Hyperglyceia at hospital admission is associated with severity of the prognosis in patients hopsitalized for COVID-19: the Pisa COVID-19 study.
Diabetes Care. 2020;43:2345-48.• Overall All-Cause Mortality
• 41.1% with admission blood
glucose >180 mg/dL
• 33% with admission blood
glucose 140-180 mg/dL
• 15.7% with admission blood
glucoseGlycemic Targets
Glycemic Recommendations for nonpregnant adults with diabetes
ADA
A1CHow Are We Doing?
Kazemian P,e t al. Evaluation of the Cascade of Diabetes Care in the United States, 2005-2016. JAMA Intern Med. 2016; 179(10):1376-85.Type 2
Pharmacologic
Treatment
Diabetes Care. 2021;44 (Suppl 1):S111-24.Biguanide
Generic/trade name Site of action Common side A1c lowering FBG lowering Considerations
effects effects effect
Metformin Liver, skeletal Diarrhea, nausea, If GFR < 30, do
(Glucophage,Glucophage muscle, abdominal pain, not use
XR, Fortamet, Riomet, adipose tissue metallic taste 1% - 2% 60 – 80 mg/dL
Glumetza) Weight neutral If GFRMetformin
and COVID-19
• Retrospective study of 6256
patients hospitalized with
COVID
• Compared patients with type
2 diabetes or obesity who
had been on metformin at
home to those who had not
• Metformin was associated
with decreased mortality in
women with obesity or type 2
diabetes who were admitted
to the hospital with COVID
Bramante CT, et al. Metformin and risk of mortality in patients hospitalised with
COVID-19: a retrospective cohort analysis. Lancet Healthy Longev. 2021;2:e34-41.Dipeptidyl Peptidase-4 Inhibitors • Incretin Enhancers • Inhibits DPP-4 increasing the amount of endogenous GLP-1 • Therapeutic effects • Enhancing glucose dependent insulin secretion • Reduce hepatic glucagon production • Lowering effect primarily on postprandial levels
Dipeptidyl Peptidase-4 Inhibitors
Generic/trade name Site of Common side A1c lowering Considerations
action effects effects
Sitagliptin (Januvia) Report signs of
pancreatitis
Saxagliptin (Onglyza)
GI Tract Well tolerated, 0.6% - 0.8%
headache Saxagliptin and alogliptin
Linagliptin (Tradjenta) can increase risk of heart
failure.
Alogliptin (Nesina)DPP-4 Inhibitors and
COVID-19
• ACE2 is the entry receptor for SARS-CoV-2
• DPP4 is the entry receptor for MERS-CoV
• DPP4 is associated with maintaining lymphocyte composition and
function
• May modulate cytokines, chemokines, and peptide hormones
Chen CF, et al. Role of dipeptidyl peptidase-4 inhibitors in patients with diabetes infected with coronavirus-19. J Chin Med Assoc. 2020;83(8):710-1.• 338 patients with type 2 diabetes and COVID-19 admitted in Northern Italy hospitals
• 169 started on sitagliptin + standard of care
Sitagliptin Treatment • 169 were on standard of care only
May Improve • Treatment with sitagliptin at the time of hospitalization was associated with reduced
mortality (18% vs. 37%) with an improvement in clinical outcomes (60% vs. 38%) and
with a greater number of hospital discharges (120 vs. 89) compared with patients
Outcomes receiving standard of care, respectively.
Solerte SB, et al. Sitagliptin Treatment at the Time of Hospitalization Was Associated With Reduced Mortality in Patients With Type 2 Diabetes and COVID-19: A Multicenter, Case-
Control, Retrospective, Observational Study. Diabetes Care:2020;2999-3006.Sodium Glucose
Cotransporter 2
Inhibitors
Vhao EC. SGLT-2 Inhibitors: a new mechanism for glycemic control. Clin Diabetes 2014;32:4-11Sodium Glucose Cotransporter 2 Inhibitors:
Benefits
• Lower A1C b 0.6% to 1.5%
• Reduce weight by ~3 to 4 kg
• Reduce systolic BP by ~ 5 to 6 mmHg
• Low risk of hypoglycemia
• May be renal protective
Peene et al. sodium glucose transporter protein 2 inhibitors: focusing on the kidney to treat type 2 diabetes. Ther Adv Endocrinol Metab. 2014;5:124-36.SGLT-2 Inhibitors
Generic/trade name Site of Common side A1c lowering Considerations
action effects effects
Canaglifozin Monitor GFR:
(Invokana) • Canagliflozin: do not use if GFRSGLT-2 Inhibitors and COVID-
19
• COVID-19 may increase insulin demand and
present with gastrointestinal symptoms
• SGLT-2 inhibitors predisposes a patient to volume
depletion
• Rare complication: diabetic
ketoacidosis/euglycemic DKA
• These agents should be discontinued in any patient
suspected of having COVID-19 due to the increased
risk of DKA
Fang J, et al. COVID-19 precipitating euglycaemic diabetic ketoacidosis with SGLT2 inhibitor use. Eur J Case Rep Intern Med. 2020;7(11):001943Glucagon-like Peptide 1 Receptor Agonists
Generic/trade name Common side A1c lowering Considerations
effects effects
Exenatide (Byetta) Black box warning: Thyroid C-cell
Exenatide XR tumor warning for exenatide XR,
(Bydureon) Nausea, diarrhea, 0.5% - 1.6% liraglutide, dulaglutide, and
weight loss semaglutide (avoid if family history of
Liraglutide (Victoza)* injection site pain,
medullary thyroid tumor).
Dulaglutide (Trulicity)* headache
Report signs of *Significantly reduces risk of CV death,
Lixisenatide (Adlyxin) acute pancreatitis heart attack, and stroke.
Semaglutide
(Ozempic*, Rybelsus)GLP-1 RAs and COVID-19 • May be protective against CVD and kidney disease • Has the potential to help patients lose weight • Recommended to continue treatment during the pandemic
Antidiabetic Treatment During COVID19 Apicella M, et al. COVID-19 in people with diabetes: understanding the reasons for worse outcomes. Lancet Diabetes Endocrinol. 2020:8;782-92.
Recommendations for Diabetes Care Bornstein SR, et al. Practical recommendations for the management of diabetes in patients withCOVID-19. Lancet Diabetes Endocrinol. 2020;8:546-50.
Key Guidance for Persons with Diabetes
• Prevention
• Reudce exposure to the virus
• Follow current CDC guidelines and local recommendations
• Reduce risk of severe illness
• Improve baseline health status
• Manage blood glucose levels
• Prepare in advance of illness
• Sick day diabetes management plan
• Ensure adequate insulin, medications, diabetes suppliesSick Day Management
• Stay hydrated
• 8oz sugar-free and caffeine-free liquids every hour
• If unable, frequent sips of liquid
• Sugar free popsicles, sugar free gelatin
• Try to follow regular meal plan
• If unable to eat, substitute regular carbohydrate intake with liquids
• Regular soda, gelatin, popsicles, Gatorade or Pedialyte, sherbet, soup
• Monitoring
• Blood glucose at least every 4 hours or continuous monitoring
• Ketones (urine or blood) every 4 hours• If blood glucose is greater than 300 mg/dL if using insulin injections
or 240 mg/dL if on an insulin pump
• When ill or vomiting
• Symptoms
• Frequent urination
Ketone • Excess thirst
• Nausea/vomiting
Monitoring • Stomach pain
• Flushed skin
• Weakness
• Rapid heartrate
• Shortness of breath
• Deep or troubled breathing
• ConfusionCDC Advice for People with Diabetes
• Having type 2 diabetes increases your risk of severe illness from COVID-19. Based on what we know at this
time, having type 1 or gestational diabetes might increase your risk of severe illness from COVID-19.
• Actions to take
• Continue taking your diabetes pills and insulin as usual.
• Test your blood sugar and keep track of the results, as directed by your healthcare provider.
• Make sure that you have at least a 30-day supply of your diabetes medicines, including insulin.
• Follow your healthcare provider’s instructions if you are feeling ill as well as the sick day tips for people
with diabetes.
• Call your healthcare provider if you have concerns about your condition or feel sick.
• If you don’t have a healthcare provider, contact your nearest community health centerexternal
icon or health department.• Minimize physical interactions with others • Maintain strict personal hygiene • Avoid touching face with unwashed hands • Routinely disinfect high-touch surfaces in home • Avoid any non-essential travel • Convert healthcare visits to telemedicine where possible • Extra precautions when out in public: • Cloth mask or face covering • Maintain 6 feet distance
Summary
• The risk of developing COVID-19 is not
greater for those with diabetes
• In-hospital mortality and disease severity
may be worse
• Important to stress glucose control
• Do not prophylactically discontinue
medication
• Stress the importance of continuing
preventative measures to prevent
COVID infection
Apicella M, et al. COVID-19 in people with diabetes: understanding the reasons for
worse outcomes. Lancet Diabetes Endocrinol. 2020:8;782-92.Resources https://professional.diabetes.org/content-page/covid-19
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