Letter to the Editor: Diabetes patients with COVID-19 need better blood glucose management in Wuhan, China
Authors: Jun Zhou, Jie Tan
Journal: Metabolism (2020)

Coronavirus Disease 2019 (COVID-19) has aroused worldwide public health concerns in recent days [[1]Lai C. Shih T. Ko W. Tang H. Hsueh P. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirusdisease-2019 (COVID-19): the epidemic and the challenges.Int J Antimicrob Agents. 2020; 105924Google Scholar]. Diabetes has been reported as one of the most common comorbidities and correlated with higher mortality [[2]Yang X. Yu Y. Xu J. Shu H. Xia J. Liu H. et al.Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumoniain Wuhan, China: a single-centered, retrospective, observational study.Lancet Respir Med. 2020; https://doi.org/10.1016/S2213-2600(20)30079-5Abstract Full Text Full Text PDF Scopus (6897) Google Scholar,[3]Huang C. Wang Y. Li X. Ren L. Zhao J. Hu Y. et al.Clinical features of patients infected with 2019 novel coronavirus in Wuhan,China.Lancet (London, England). 2020; 395: 497-506Abstract Full Text Full Text PDF PubMed Scopus (32456) Google Scholar]. In order to investigate current blood glucose (BG) management of the patients with both diabetes and COVID-19, we retrospectively analyzed 29 inpatients diagnosed with type-2 diabetes and laboratory-confirmed COVID-19 and admitted to a designated isolation medical center in Wuhan from February 13th to March 1st. These patients had a median (range) age of 69 (54–81) years old and diagnosed with diabetes for 6 (1.5–14) years. All patients had at least one BG test. The clinical management varies according to their BG levels and physicians' advice. We utilized the BG targets suggested for inpatients by the American Association of Clinical Endocrinologists and American Diabetes Association, 7.8 mmol/L for preprandial BG and 10.0 mmol/L for postprandial BG, as the cutoff values [[4]Moghissi E.S. Korytkowski M.T. DiNardo M. Einhorn D. Hellman R. Hirsch I.B. et al.American Association of Clinical Endocrinologists and American DiabetesAssociation consensus statement on inpatient glycemic control.Diabetes Care. 2009; 32: 1119-1131Crossref PubMed Scopus (977) Google Scholar]. A total of 881 capillary BG tests were performed for these patients. Among them, 56.6% (499/881) of the tests showed abnormal BG levels, including 29.4% (58/197) of the preprandial BG tests and 64.5% (441/684) of the postprandial tests. 69.0% (20/29) patients were considered with non-ideal BG levels. And 10.3% (3/29) of the patients suffered at least one episode of hypoglycemia (<3.9 mmol/L). These results suggested a failure of current BG management strategies for patients suffering both diabetes and COVID-19, especially that of postprandial BG. As diabetes and hyperglycemia may lead to higher secondary infection risk and mortality [5Tseng C. Mortality and causes of death in a national sample of diabetic patients inTaiwan.Diabetes Care. 2004; 27: 1605-1609Crossref PubMed Scopus (199) Google Scholar, 6Yang J.K. Feng Y. Yuan M.Y. Yuan S.Y. Fu H.J. Wu B.Y. et al.Plasma glucose levels and diabetes are independent predictors for mortality andmorbidity in patients with SARS.In. 2006; : 623-628Google Scholar, 7Kechagias S. Nasr P. Blomdahl J. Ekstedt M. Established and emerging factors affecting the progression of nonalcoholic fatty liver disease.Metab Clin Exp. 2020; 154183Google Scholar], we suggest that the BG management of these patients should be better valued and optimized. Given the current situation of Wuhan's healthcare system, we infer the potential reasons are as follows: 1) There is a relative shortage of available professional endocrinologists in designated isolation medical centers, leading to delay or absence of professional advice. 2) Diet for COVID-19 patients is uniformly provided. A diabetic diet or personalized diet is unavailable. 3) Quarantined inpatients are unable to exercise due to limited indoor space and poor pulmonary function. 4) The anxiety led by COVID-19 induces hyperglycemia [[8]Miazgowski T. Bikowska M. Ogonowski J. Taszarek A. The impact of health locus of control and anxiety on self-monitored blood glucose concentration in women with gestational diabetes mellitus.In. 2018; : 209-215Google Scholar]. 5) Pancreatic tissue is a potential target of viral infection, leading to glucose metabolism disorders [[9]Yang J. Lin S. Ji X. Guo L. Binding of SARS coronavirus to its receptor damages islets and causes acutediabetes.Acta Diabetol. 2010; 47: 193-199Crossref PubMed Scopus (731) Google Scholar,[10]Hamming I. Cooper M.E. Haagmans B.L. Hooper N.M. Korstanje R. Osterhaus A.D.M.E. et al.The emerging role of ACE2 in physiology and disease.J Pathol. 2007; 212: 1-11Crossref PubMed Scopus (343) Google Scholar]. We hereby suggest 1) Establish an electronic blood glucose record and remote consultation system to flexibly utilize the resources of local endocrinologists or professionals nationwide. 2) Coordinate with nutritionists and hospital canteens to offer diabetic diet. 3) Provide indoor exercise instructions. 4) The anxiety levels of inpatients should be evaluated. Psychological intervention should be carried out for patients in need. 5) Further pathophysiological studies are needed. Clinical practice and related social resources allocation in today's Wuhan city may differ from that of other places with adequate medical resources. However, this Wuhan experience may help other cities learn how to better respond to the COVID-19 outbreak. In this letter, we demonstrate that BG management strategies for diabetes patients with COVID-19 should be optimized. Further clinical and pathophysiological studies are needed to establish more details. The authors receive no funding and declare no conflict of interest. We thank the Chinese government and citizens for their quick response to the COVID-19 outbreak and generous support to the healthcare system in Wuhan city. J. Z. and J. T. designed the study; J. Z. collected and analyzed clinical data; J. Z. and J. T. completed the manuscript.