Ask the Expert: Diabetes & COVID-19
By: Marcel B. Twahirwa, MD
Medical Director at DHR Health Diabetes and Endocrinology Institute
What are the general risks of a person with diabetes getting COVID-19?Diabetes, as we know, is one of the most prevalent chronic conditions in our country, over 34.2 million Americans are living with this disease (ADA, 2018). Having diabetes alone does not increase the risk of getting COVID-19; the risk is the same as any person without this condition. Thus, it is crucial to understand the risks of transmission of this virus and do everything possible to help prevent it. Social distancing, hand washing, and wearing a face mask are essential measures we can take to help lessen the risk.
Should I be concerned if I am diabetic and test positive for COVID-19?If you have diabetes and test positive, there is a reason to be concerned because people with diabetes have a higher chance of becoming ill and experiencing severe complications. Patients with diabetes are more likely to have serious complications, more intensive care unit admissions, extended length of stay, and death from COVID 19. Recent studies have shown that of hospitalized patients with COVID-19 experiencing severe complications, 22.2% to 26.9% reported living with diabetes. In one retrospective study from the United States, the mortality rate was 14.8% in patients with diabetes and patients with uncontrolled diabetes or pre-diabetes, the mortality rate doubled (28.8%). For this reason, taking extra precautions to protect yourself is imperative. If you test positive, the first thing is to remain calm, stay home, and start monitoring your blood sugar more often via finger stick or with a continuous glucose monitoring (CGM) device. Make sure you have all your medications for your diabetes nearby and contact your healthcare provider if you start to notice your blood sugar increasing. When you have diabetes that is not well uncontrolled, having high blood sugars suppresses your immune system function, which can lead to your body having a harder time fighting off the viral infection. So be proactive in your diabetes management, remember you can't control the virus, but you can control your diabetes!
Is there a difference between Type 1 Risks & Type 2 Risks?Poorly controlled diabetes is a risk factor for infection in general. As of today, there is limited data evaluating COVID-19 in patients with type 1 diabetes. However, both diabetes and obesity appear to be independent risk factors for experiencing severe complications from COVID-19. Analysis of the National Diabetes and mortality data from the United Kingdom before and during the COVID-19 pandemic, noted mortality risk was higher with hba1c above 7.5% and continued to increase as hemoglobin A1c levels rose. Obesity was also associated with increased mortality in both type 1 type 2 diabetes. COVID-19 appears to precipitate severe elevation in blood glucose in patients with diabetes. In type 2 diabetes, COVID-19 may accelerate a clinical picture known as a hyperosmolar state, which frequently may cause patients to go into a coma. In type 1 diabetes, COVID-19 may precipitate diabetes ketoacidosis where patients cannot metabolize blood glucose and plunge into a state of severe metabolic acidosis. Both conditions increase the risk of in-hospital mortality.
We have unique challenges in South Texas. We rank at the top in the prevalence of diabetes and obesity in the nation. Dr. McCormick group found that around ⅔ of the Mexican American population in South Texas has diabetes or pre-diabetes. Diabetes prevalence is 28%, pre-diabetes is 31.6%, with nearly 50% of those patients undiagnosed. Also, 38.2% were found to be heavy smokers. So we have three critical conditions in the RGV community that make our populations most vulnerable to acquire severe COVID-19 outcomes, which consist of diabetes, obesity, and smoking. In another study conducted that looked at almost 1000 Cameron County men, Dr. McCormick and his group showed, diabetes prevalence in men under the age of 35 was 16.7% and 26% in men overall.
Recommendations for patients with diabetes and COVID-19 in the outpatient setting,
Patient with T2DM and COVID19
- If patients can maintain proper hydration with fluid intake, they may or should continue to take their medications. Both oral and injectable medications should continue and may need to be adjusted if glucose levels begin to change. For example: for those patients who are unable to eat or maintain suitable hydration, the use of SGLT-2 inhibitors such as Invokana, Farxiga, Steglatro, and Jardiance or combination of medication that might include this class of drugs should be avoided. These medications may increase the risk of dehydration, genitourinary tract infections, and increase caloric loss. In rare situations, patients who are limiting caloric intake may precipitate and develop diabetic ketoacidosis. Patients who can maintain a healthy diet and fluid intake should continue to take these medications.
- Patients who may be experiencing nausea or diarrhea may consider holding their GLP -1 receptor agonists medications, such as Victoza, Bydureon, Trulicity, and Ozempic. Metformin should also be held since a common side effect of metformin can be diarrhea and gastrointestinal symptoms may need to be stopped.
- Patients taking insulin, may require dose adjustment on current insulin regimens. For this reason, frequent monitoring and contacting your health care provider is essential.
For those patients with type 1 diabetes and COVID19:
- More frequent blood glucose checks either by finger stick (every 2-4 hrs) or by using continuous glucose monitoring device (freestyle Libre or Dexcom) are strongly advised.
- If hyperglycemia is detected (usually more than 240 mg per dL), it is necessary to monitor for urinary ketones or finger stick ketones (home test).
- Adjustment of insulin doses according to blood glucose may be needed, given fluctuations in glucose levels.
- If nausea/vomiting or large ketones persist or are present, patients should seek emergency medical attention given it could be indicating the presence of diabetic ketoacidosis.
Lastly, we strongly advised all patients with diabetes or other chronic conditions to use Telehealth. This technology can save lives by limiting unnecessary exposure to COVID-19.
Reference
Center for Disease Control (DED) The Precarious Health of Young Mexican American Men in South Texas, Cameron County Hispanic Cohort, 2004-2015. Retrieved from: https://www.cdc.gov/pcd/issues/2016/16_0020.htm on July 20, 2020.
Undiagnosed Diabetes and Pre-Diabetes in Health Disparities. Retrieved from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0133135 on July 20, 2020
