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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 5  |  Issue : 2  |  Page : 58-62

Managing diabetes and COVID-19: A national strategic framework


1 Dr. Mohan's Diabetes Specialities Centre and Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India
2 Member, Indian Society for Clinical Research, Bengaluru, Karnataka, India

Date of Submission26-May-2020
Date of Decision11-Jun-2020
Date of Acceptance11-Jun-2020
Date of Web Publication29-Jun-2020

Correspondence Address:
Dr. Viswanathan Mohan
Dr. Mohan's Diabetes Specialities Centre and Madras Diabetes Research Foundation, IDF Centre of Excellence in Diabetes Care and ICMR Centre for Advanced Research on Diabetes, No. 4, Conran Smith Road, Gopalapuram, Chennai . 600 086, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jncd.jncd_39_20

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  Abstract 


The coronavirus disease (COVID-19) pandemic has been one of the greatest health challenges that humanity has witnessed in recent times. Diabetes mellitus is one of the most common noncommunicable diseases and its prevalence is very high in evlderly people. COVID-19 also has a worse prognosis in elderly people. Hence, most of the data, both nationally and internationally, have shown that people with uncontrolled diabetes have worse outcomes compared to people without diabetes. This article reviews the connection between diabetes and COVID-19 and suggests various precautions to be taken for people with diabetes, the management strategies for diabetes and lays down a strategic framework for managing people with diabetes and COVID-19.

Keywords: COVID-19, diabetes, higher risk, infection, precautions


How to cite this article:
Mohan V, Ramesh J. Managing diabetes and COVID-19: A national strategic framework. Int J Non-Commun Dis 2020;5:58-62

How to cite this URL:
Mohan V, Ramesh J. Managing diabetes and COVID-19: A national strategic framework. Int J Non-Commun Dis [serial online] 2020 [cited 2020 Oct 26];5:58-62. Available from: https://www.ijncd.org/text.asp?2020/5/2/58/288257




  Introduction Top


Diabetes is among the most prevalent chronic diseases, affecting the health of millions of people, and is a known major public health problem worldwide.[1],[2] As per the International Diabetes Federation estimates, in 2019, approximately 463 million adults (20–79 years age-group) were living with diabetes across the world. This is estimated to rise to 578 million by 2030 and to 700 million by 2045. The proportion of people with type 2 diabetes is increasing in most countries, with 79% of adults with diabetes now living in low- and middle-income countries.[1] In India, diabetes has been a very significantly growing public health problem over the past three decades, and currently, there are an estimated 77 million people living with diabetes.[1],[3] The burden of diabetes is increasing rapidly across all the regions and states of India, and in addition to the high prevalence in large urban areas, is now also prevalent in the smaller cities and rural areas.[3],[4] Diabetes is an important risk factor for cardiovascular disease (CVD) and other serious medical complications, with CVD being the most important cause of morbidity and mortality in these patients.[5],[6] Overall, cardiovascular (CV) risk factors such as hypertension, dyslipidemia, and obesity are common in patients with diabetes, all of which are associated with increased risk for the development of CV events.[5]

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus known as severe acute respiratory syndrome coronavirus 2.[7] In March 2020, the World Health Organization (WHO) had declared the COVID-19 outbreak to be a pandemic and a public health emergency of international concern.[7] Most people infected with the COVID-19 will experience mild-to-moderate respiratory illness and recover without requiring special treatment. Older people and those with underlying medical problems such as CVD, diabetes, chronic respiratory disease, and cancer (comorbidities) are more likely to develop a serious illness due to COVID-19.[7],[8] Since the report of the first known case of coronavirus infection from Wuhan, China, the number of people affected by COVID-19 has been growing very quickly across all regions of the world, with most countries affected.[7] In India, the number of people affected by COVID-19 has been steadily increasing and has been reported from most states and regions of the country.[9]

In this article, we discuss the important aspects of management of patients with diabetes who have been affected by COVID-19, with special focus on those with comorbid health conditions and the elderly, both of whom are at higher risk and worse outcomes due to COVID-19. A strategic approach and framework is proposed for consideration at the national level for people with diabetes and those confirmed to be affected by COVID-19.


  Higher Risk for People With Diabetes to Develop COVID-19 Top


People with diabetes have an increased risk of developing a number of serious health complications, known as comorbidities. Consistently, high blood glucose levels can lead to serious diseases such as CVD, i.e., Myocardial infarction and stroke, in addition to diabetic retinopathy, diabetic nephropathy, also called diabetic kidney disease and peripheral neuropathy. It is well known across the world that diabetes is a leading cause of CVD, blindness, kidney failure, and lower limb amputation.[1]

In addition, people with diabetes also have a higher risk of developing infections, including serious ones.[1],[10] In a study comparing people with diabetes to control group without diabetes, it was found that people with diabetes had higher rates for all infections, with the highest rates seen for bone and joint infections, sepsis, and cellulitis.[10] Further, in the same study, it was estimated that 6% of infection-related hospitalizations and 12% of infection-related deaths were attributable to diabetes.[10] Hyperglycemia in people with diabetes is likely to cause dysfunction of the immune response, which, in turn, leads to failure to control the spread of invading pathogens in these people. Hence, people with diabetes are very susceptible to infections like COVID-19.[11] The reasons why people with diabetes are at higher risk to develop COVID-19 are summarized in [Table 1].
Table 1: Factors for people with diabetes being at higher risk to develop COVID-19

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  Precautions for People With Diabetes to Prevent or Reduce Chances of Developing COVID-19 Top


People with preexisting medical conditions (such as diabetes, heart disease, and asthma) and older people, in general, appear to be more vulnerable to becoming severely ill with the COVID-19.[1],[8] The precautions advised to the general population to reduce the chances of developing COVID-19 are all recommended for people with diabetes, in addition, as few specific precautions and recommendations are also necessary.[1],[8] This is important as currently there is no approved vaccine for the prevention of COVID-19 and very limited treatment options for those with confirmed coronavirus infection. The general and specific precautions to be taken by people with diabetes and recommendations advised are summarized in [Table 2].
Table 2 : Precautions for people with diabetes to prevent or reduce the chances of developing COVID-19

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  Management of Diabetes in Those With Confirmed COVID-19 Top


In case a person with diabetes develops symptoms of fever, cough or difficulty in breathing, it is appropriate to immediately contact a doctor (initial contact to be through phone, unless very severe symptoms). The doctor, based on any suspicion of a potential coronavirus infection, may refer the patient to a nearby or suitable authorized hospital for further investigation (testing for COVID-19 with isolation, etc.).[12],[13] In case the person is confirmed to have COVID-19, further management will be as per the Indian Council for Medical Research recommended guidelines.[13]

For people with diabetes who have been confirmed to have COVID-19, it is important to have regular blood glucose monitoring and have adequate glycemic control. This is likely to reduce the risk of severe COVID-19. There are specific considerations regarding the use of and also need to avoid some anti-hyperglycemic agents. In type 2 diabetes, the initial pharmacological agent of choice, metformin, has risks of dehydration and lactic acidosis. Hence, people with diabetes and who have the potential to progress to severe COVID-19 (e.g., who have greater dehydration) should stop taking this drug. The therapeutic class of dipeptidyl peptidase (DPP)-4 inhibitors (alogliptin, linagliptin, saxagliptin, sitagliptin, and others) is generally well tolerated and can be continued in these patients. Sodium-glucose co-transport-2 inhibitors (canagliflozin, dapagliflozin, and empagliflozin) are associated with risks of dehydration and diabetic ketoacidosis, and hence, patients who are prone to infections or have higher chances of severe COVID-19 should stop taking this drug. Glucagon-like peptide -1 receptor agonists (dulaglutide, exenatide-extended release, liraglutide, and semaglutide) also have a risk of dehydration, so patients on this group of drugs should be closely monitored. Importantly, if any anti-hyperglycemic drugs are discontinued, the alternative treatment of choice is usually insulin. Further, if insulin therapy is already ongoing in a patient, it should be continued and not stopped. For type 1 diabetes and COVID-19, there is clear need more frequent and close blood glucose monitoring and adjustments of insulin dose based on blood glucose values. Overall, the patient and treating physician together should individualize the management of diabetes by assessing and carefully adjusting regular therapy to reach individualized therapeutic goals according to diabetes type, comorbidities, and health status.

The treatment goals and recommendations for patients who have been in reasonably good control and in the out-patient setting (e.g., isolation or quarantine) and do not require hospitalization/intensive care admission due to COVID-19 is summarized in [Table 3].
Table 3: Treatment goals and recommendations for managing diabetes, for those with confirmed COVID-19

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  Elderly People With Diabetes and COVID-19 Top


COVID-19 is a new disease, and currently, there is limited information regarding the risk factors for the severe form of the disease. The current information, clinical knowledge, and expertise suggest that older adults (over 65 years of age) and people of any age who have serious underlying medical conditions such as diabetes, heart disease, and asthma are likely at higher risk for severe illness from COVID-19.[1],[8] Those who are at higher risk for developing a severe form of COVID-19 are listed in [Table 4]. This is an important point to consider as many people with diabetes may have one or more of these as co-existing medical conditions.[1],[8]
Table 4: People at high-risk for severe illness from COVID-19

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The elderly population are an important and quite a heterogeneous group living with diabetes. Older individuals with diabetes have higher rates of premature death, functional disability, accelerated muscle and bone loss, and co-existing conditions, such as hypertension, coronary heart disease, and stroke. Older adults with diabetes also are at greater risk than other older adults for several common geriatric problems, such as polypharmacy (due to multiple health conditions), cognitive impairment, urinary incontinence, injurious falls, and persistent pain.[14] Further, the elderly have a unique biomedical and psychological make-up and further may be living in varied social environments. Hence, their daily, as well as healthcare needs, are different from younger adults.[15] Diabetes management in the elderly should focus on prevention and limiting the impact of geriatric medical conditions (i.e., those encountered in elderly persons), hypoglycemia (low blood glucose levels), and neurodegenerative conditions (impairment in the functioning of nervous system and brain).[15]

When older people with diabetes develop a viral infection such as COVID-19, it is harder to treat due to fluctuations in blood glucose levels and possibly, the presence of diabetes complications and other comorbid conditions such as hypertension, coronary heart disease, and stroke.[1] There appear to be two reasons for this. First, the immune system is compromised, making it harder to fight the virus and likely leading to a longer clinical recovery period. Second, the virus may also thrive better in an environment of elevated blood glucose.

Older people with diabetes and COVID-19 have high risks of severe illness with morbidity and mortality, as discussed above. Hence, while these individuals take all precautions and manage their symptoms of COVID-19 well, it is equally important that their diabetes in managed optimally and treatment is individualized.[16] The key recommendations for the management of diabetes are highlighted in [Table 5].[14]
Table 5: Key recommendations for the management of diabetes in older adults who have COVID-19

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Special care is required in prescribing and monitoring pharmacologic therapies in older adults with diabetes.[14] The latest general recommendations regarding anti-hyperglycemic treatment for adults with type 2 diabetes and children and adults with type 1 diabetes are available and should be referred to.[17] In addition, patient- and drug-specific factors should be considered when selecting anti-hyperglycemic agents, especially as older adults tend to be on many medications.[17] Older adults with diabetes often have multiple comorbidities such as hypertension, dyslipidemia, respiratory disease, kidney impairment, and others. Specific antihyperglycemic agent classes have to be selected carefully based on these factors.[17] Overall, for older people with diabetes and confirmed COVID-19, safer oral anti-hyperglycemic agents, and insulins with careful dosage adjustment based on regular blood glucose monitoring) are recommended as the preferred treatment for obtaining optimal glucose control.


  Strategic Framework for Managing People With Diabetes and COVID-19 Top


A strategic framework at the National level in India for the optimal management of people with diabetes and confirmed COVID-19 is likely to be very helpful for better health outcomes for patients with cost-efficient use of available health-care resources. The WHO since declaring COVID-19 as a pandemic has recently also suggested that COVID-19 could continue to affect countries across the world, even if the current pandemic subsides, suggesting the possibility of outbreaks later in the year. Further, there are limited treatment options for COVID-19 currently, and vaccines for the prevention of COVID-19 are all currently under development and not available at present. This framework is expected to be very helpful as India has a very significantly growing population that is affected by diabetes, affecting all regions and states, age-groups (young, middle-aged, and elderly), and all socioeconomic strata, both in urban and rural areas. Similarly, the number of people with confirmed COVID-19 has been increasing rapidly across the country, and currently, over 75,000 cases have been reported, with people of different age-groups and socioeconomic backgrounds affected. Further, current knowledge reveals that elderly people are more vulnerable to severe illness with COVID-19 with worse outcomes, including higher mortality. The key elements of the proposed framework are listed in [Table 6]. This could be planned at the National level with key stakeholders in both public and private health-care domains involved, who can lead the overall strategy and be implemented at the regional and local health-care level.
Table 6: Key elements of the proposed Strategic framework for the management of people with diabetes and COVID-19

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  Summary Top


Diabetes continues to a very significant and growing public health problem across the world and in India. The recent outbreak of coronavirus infection across the world and it being designated as a global pandemic by WHO, has severely affected people in general and even more so, those who have confirmed COVID-19. In people with both diabetes and COVID-19, the morbidity is greater and those older in age or with comorbidities have significantly increased risk of mortality. The optimal management of these people with the most appropriate available health-care resources using a strategic framework are expected to result in better health outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
International Diabetes Federation (IDF), IDF Diabetes Atlas Ninth Edition 2019. Available from: https://www.idf.org/aboutdiabetes. [Last accessed on 2020 May 04].  Back to cited text no. 1
    
2.
Ingelfinger JR, Jarcho JA. Increase in the Incidence of Diabetes and Its Implications. N Engl J Med 2017;376:1473-4.  Back to cited text no. 2
    
3.
Tandon N, Anjana RM, Mohan V, Kaur T, Afshin A, Ong K, et al. India state-level disease burden initiative diabetes collaborators. The increasing burden of diabetes and variations among the states of India: The global burden of disease study 1990-2016. Lancet 2018;6:E1352-62.  Back to cited text no. 3
    
4.
Anjana RM, Deepa M, Pradeepa R, Mahanta J, Narain K, Das HK, et al. Prevalence of diabetes and prediabetes in 15 states of India: Results from the ICMR-INDIAB population-based cross-sectional study. Lancet Diabetes Endocrinol 2017;5:585-96.  Back to cited text no. 4
    
5.
Leon BM, Maddox TM. Diabetes and cardiovascular disease: Epidemiology, biological mechanisms, treatment recommendations and future research. World J Diabetes 2015;6:1246-58.  Back to cited text no. 5
    
6.
Pradeepa R, Mohan V. Prevalence of type 2 diabetes and its complications in India and ecnomic costs to the nation. Eur J Clin Nutr 2017;71:816-24.  Back to cited text no. 6
    
7.
World Health Organization, Geneva, Switzerland. Available from: https://www.who.int/health-topics/coronavirus. [Last accessed on 2020 May 04].  Back to cited text no. 7
    
8.
Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA. Available from: https://www.cdc.gov/coronavirus/2019. [Last accessed 2020 May 08].  Back to cited text no. 8
    
9.
Ministry of Health and Family Welfare (MoHFW), Government of India, New Delhi, India. Available from: https://www.mohfw.gov.in. [Last accessed on 2020 May 08].  Back to cited text no. 9
    
10.
Carey IM, Critchley JA, DeWilde S, Harris T, Hosking FJ, Cook DG. Risk of infection in type 1 and type 2 diabetes compared with the general population: A matched cohort study. Diabetes Care 2018;41:513-21.  Back to cited text no. 10
    
11.
Berbudi A, Rahmadika N, Tjahjadi AI, Ruslami R. Type 2 diabetes and its impact on the immune system. Curr Diabetes Rev 2020;16:442-9.  Back to cited text no. 11
    
12.
Gupta R, Ghosh A, Singh AK, Misra A. Clinical considerations for patients with diabetes in times of COVID-19 epidemic. Diabetes Metab Syndr 2020;14:211-2.  Back to cited text no. 12
    
13.
Indian Council for Medical Research (ICMR). Available from: https://www.icmr.gov.in/. [Last accessed on 2020 May 08].  Back to cited text no. 13
    
14.
American Diabetes Association; Older adults: Standards of medical care in diabetes–2019. Diabetes Care 2019;42 Suppl 1:S139-47.  Back to cited text no. 14
    
15.
Kalra S, Sharma SK. Diabetes in the elderly. Diabetes Ther 2018;9:493-500.  Back to cited text no. 15
    
16.
Mohan V, Das AK, Mukherjee JJ, Seshadri K, Jha S, Kalra S. From individualized to personalized medicine in diabetes: An expert overview. J Assoc Physicians India 2019;67:78-82.  Back to cited text no. 16
    
17.
American Diabetes Association. Position Statements Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes2020. Diabetes Care 2020;43(Supplement 1):S98-110.  Back to cited text no. 17
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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