Management of diabetes in patients with COVID-19
Authors: Medha N Munshi, Sarah L Sy
Journal: The Lancet Diabetes & Endocrinology (2020)

We read with great interest the Personal View by Stefan Bornstein and colleagues1Bornstein SR Rubino F Khunti K et al.Practical recommendations for the management of diabetes in patients with COVID-19.Lancet Diabetes Endocrinol. 2020; 8: 546-550Summary Full Text Full Text PDF PubMed Scopus (613) Google Scholar on the management of diabetes in patients with COVID-19. During these unprecedented times, more guidance is required to care for this high-risk population. The authors recommend intensification of glucose control to prevent COVID-19, suggesting an HbA1c of less than 53 mmol/mol (<7%) and plasma glucose concentration of 4–8 mmol/L (72–144 mg/dL) for most patients, and 5–8 mmol/L (90–144 mg/dL) for frail patients. These glycaemic goals for the older population are much tighter than suggested in most guidelines. Older patients with diabetes are a heterogeneous population with varying levels of complexity, multimorbidity, geriatric syndromes, functional abilities, and life expectancy. Some patients rely on caregivers, whereas others live in assisted living facilities or long-term care facilities. Consideration of these factors when deciding on glycaemic goals is even more critical at this time because older adults are in isolation and support from family, caregivers, or nurses might be limited. Previous studies have shown that intensive control (HbA1c <7%) in older adults with diabetes did not lead to a significant reduction in cardiovascular events, and conversely, increased the risk of hypoglycaemia and death.2Duckworth W Abraira C Moritz T et al.Glucose control and vascular complications in veterans with type 2 diabetes.N Engl J Med. 2009; 360: 129-139Crossref PubMed Scopus (4099) Google Scholar, 3Gerstein HC Miller ME et al.Action to Control Cardiovascular Risk in Diabetes Study GroupEffects of intensive glucose lowering in type 2 diabetes.N Engl J Med. 2008; 358: 2545-2559Crossref PubMed Scopus (6828) Google Scholar In a study of older adults aged 75 years or older with type 2 diabetes and high complexity or comorbidities,4McCoy RG Lipska KJ Yao X Ross JS Montori VM Shah ND Intensive treatment and severe hypoglycemia among adults with type 2 diabetes.JAMA Intern Med. 2016; 176: 969-978Crossref PubMed Scopus (118) Google Scholar those who were treated with intensive glycaemic control (HbA1c <7%) had double the risk of severe hypoglycaemia compared with those given standard treatment. Therefore, changes made to diabetes treatment plans must minimise the risk of hypoglycaemia, because it can lead to grave consequences such as increased falls, fractures, hospitalisations, cerebrovascular and cardiovascular events, cognitive dysfunction, and even death.5Kirkman MS Briscoe VJ Clark N et al.Diabetes in older adults.Diabetes Care. 2012; 35: 2650-2664Crossref PubMed Scopus (923) Google Scholar Although the practical recommendations provided by Bornstein and colleagues1Bornstein SR Rubino F Khunti K et al.Practical recommendations for the management of diabetes in patients with COVID-19.Lancet Diabetes Endocrinol. 2020; 8: 546-550Summary Full Text Full Text PDF PubMed Scopus (613) Google Scholar serve as an important guide for clinicians treating patients with diabetes, a different approach is needed for older adults with functional and cognitive decline, as well as those living in long-term care facilities. This approach should include avoiding any intensification or changes in medications that could lead to hypoglycaemia and increased treatment burden. In addition, for many of these patients, self-care activities such as diet and exercise routines might have been interrupted. Providing reassurance to patients can be helpful to reduce feelings of stress or guilt if their routine has not been maintained. As the pandemic unfolds and life normalises to some extent, diabetes management and glycaemic goals can be revisited. MNM is a consultant for Sanofi and Lilly. SLS declares no competing interests. Management of diabetes in patients with COVID-19 – Authors' replyWe are pleased to learn about the interest in our paper on the practical recommendations for the management of diabetes in patients with COVID-19.1 These Correspondences address important aspects regarding the use of medications and the risk of hypoglycaemia or obesity, and we are thankful for these comments. Full-Text PDF Practical recommendations for the management of diabetes in patients with COVID-19Diabetes is one of the most important comorbidities linked to the severity of all three known human pathogenic coronavirus infections, including severe acute respiratory syndrome coronavirus 2. Patients with diabetes have an increased risk of severe complications including Adult Respiratory Distress Syndrome and multi-organ failure. Depending on the global region, 20–50% of patients in the coronavirus disease 2019 (COVID-19) pandemic had diabetes. Given the importance of the link between COVID-19 and diabetes, we have formed an international panel of experts in the field of diabetes and endocrinology to provide some guidance and practical recommendations for the management of diabetes during the pandemic. Full-Text PDF Management of diabetes in patients with COVID-19We read with interest the practical recommendations for management of diabetes in patients with COVID-19 by Stefan Bornstein and colleagues1 in The Lancet Diabetes & Endocrinology. However, in the panel describing special considerations for anti-diabetic drugs, we note that two commonly used groups, sulfonylureas and pioglitazone, are missing. Of these, pioglitazone, a PPAR-γ agonist, merits further discussion because it interacts with both the mechanisms that might play a role in patients with diabetes with COVID-19, as described by Bornstein and colleagues. Full-Text PDF Management of diabetes in patients with COVID-19The recent Personal View by Stefan Bornstein and colleagues1 highlights possible susceptibility factors in patients with diabetes and obesity that could predispose to severe COVID-19-related illness. The authors incorporated useful general management guidance, but we feel that the descriptions of acute presentations were not sufficiently detailed to aid clinical management. We wish to expand on the acute metabolic presentations related to hyperglycaemia, which have been challenging to manage in the acute setting. Full-Text PDF Management of diabetes in patients with COVID-19Stefan Bornstein and colleagues1 seem to be the first to react to an unprecedented challenge regarding management of diabetes in patients with COVID-19 by offering practical recommendations. The authors state that patients with diabetes have an increased risk of severe COVID-19 complications, including acute respiratory distress syndrome. Full-Text PDF Management of diabetes in patients with COVID-19We read with interest the recommendations on the management of diabetes in patients with COVID-19 by Stefan Bornstein and colleagues.1 However, their suggestion of discontinuing metformin in patients with severe symptoms of COVID-19 (to reduce the risk of lactic acidosis) raises a number of issues. We believe that it is important to maintain a thoughtful approach to metformin therapy in patients with diabetes and COVID-19. Full-Text PDF