Diabetes Distilled: Practical recommendations for the management of diabetes in patients with COVID-19

Key messages

• People with diabetes and without COVID-19 should intensify their glycaemic control as required for the primary prevention of COVID-19 illness.
• Those without diabetes but at high risk of cardiometabolic disease who have suffered COVID-19 illness need to be monitored for new-onset diabetes that may be triggered by COVID-19 infection.
• Given the close links between diabetes and cardiovascular disease, the authors recommend continuing any concurrent statin treatment to maintain good lipid control.

The authors identify certain groups of individuals who may require specific attention:

• Those living with type 1 diabetes and elevated HbA_1c are more susceptible to infectious disease and will require more intensive monitoring and supportive therapy to reduce the risk of metabolic complications such as diabetic ketoacidosis (DKA). Specifically, those with type 1 diabetes who are taking sodium–glucose cotransporter 2 (SGLT2) inhibitors need to be aware of the significantly increased risk of DKA and reminded about presenting symptoms, ketone measurement, sick day guidance and prompt medical advice.
• Those with type 2 diabetes and fatty liver disease may exhibit an increased inflammatory response to infection and should be considered at higher risk of severe COVID-19 disease.
• Those living with diabetes and obesity are at risk of ventilatory failure and complications during mechanical ventilation. Additionally, chronic low-grade inflammation and insulin resistance is seen in those who are overweight or obese, and this impairs the immune response to all pathogens.
• The authors recommend that those with diabetes who work as healthcare professionals should be deployed away from front-line clinical duties where possible. If not possible, high-grade protection should be used.

The authors also provide a helpful table outlining special considerations on the use of diabetes drugs in suspected or COVID-19-positive individuals with type 2 diabetes. Recommendations include:

• Sick day guidance for those on metformin to reduce the risk of dehydration and lactic acidosis. Renal function should be monitored for acute kidney injury.
• Sick day guidance for those on SGLT2 inhibitors to reduce the risk of dehydration and DKA. Renal function should be monitored for acute kidney injury.
• Individuals taking glucagon-like peptide-1 receptor agonists should be monitored for dehydration and advised on adequate fluid intake and regular meals.
• Insulin therapy should not be stopped. Regular self-monitoring of blood glucose every 2–4 hours, or continuous glucose monitoring, should be encouraged.

 
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