I have been getting many calls and emails from my patients with diabetes who are understandably concerned about COVID-19 and their risk, so I thought communicating through this video/article would help people with diabetes in these desperate times.
Introduction: People with diabetes may be at an increased risk for coronavirus infection. Diabetes is one of the most common comorbidities among people infected with COVID-19.
Patients with diabetes, especially if blood glucose control is not good, fall into the high-risk categories based on the early data, which has been coming from China. In an article published in the Journal of American Medical Association, Wu and colleagues have shown that there was an increased case fatality rate for COVID-19 patients, who also had diabetes.
This article showed that the case fatality rate for patients with diabetes was 7.3% and 10.5% for those with cardiac problems or stroke.
Based on the analysis of data coming from China and Italy and published in the Journal of Endocrinological Investigation, we now know that people with diabetes are no more likely to contract COVID-19 than the general population. However, people with diabetes are twice as likely to die from the complications of COVID-19. This may in part be due to people with diabetes being more prone to develop pneumonia and inflammation. Inflammatory markers like C-reactive protein (CRP), ferritin, interleukin-6 and D-dimer were much higher in people with diabetes, who were found to be COVID-19 positive. This may explain why diabetes patients are susceptible to inflammatory storm leading Adult Respiratory Distress Syndrome (ARDS) and multiorgan failure.
We don’t know if there are any differences in the way the infection manifests in people with type 1 and type 2 diabetes.
Any illness including flu or Corona virus infection can itself increase insulin resistance and result in high blood glucose levels. However, If a person is unwell with infection and is vomiting and unable to eat or drink, they can have hypoglycaemia or low blood glucose, i.e. below 4mmol/L or 72gm/dl.
So, management of diabetes during any illness including COVID-19 infection or any flu includes:
- Prevention of the illness
- Control of blood glucose
- Prevention of hypoglycaemia
Prevention of Coronavirus infection in people with diabetes
Social distancing and isolation are now the buzzwords, which you keep hearing everywhere. Being asked to stay at home and avoid contact and travel is not easy in the long run. It can be very stressful. But having to think about diabetes when all this is going on can be overwhelming. In addition to all the factors which affect blood glucose including infection, stress can worsen this. It is therefore important to get useful information to sort your emotions and overcome stress if any.
As we all know high blood glucose reduces immunity by disrupting the action of the white blood cells. You are more susceptible to infections including influenza, any viral illness like coronavirus infection, pneumonia etc.
Poor blood glucose control leads to complications including kidney failure, heart failure and these complications in turn can further reduce lung reserve and immunity. Hence good glucose control is the key in reducing both the risk of getting infected and also reducing the severity of infection. People with diabetes should also follow the preventive measures recommended, like social distancing, self-isolation if applicable and hand washing like others.
Ensure you have adequate stock of your medications, test strips and food/drink or gel for correction of hypoglycaemia.
You should maintain good blood glucose control. This would involve checking blood glucose regularly and more often if you are not feeling well.
Are you taking steroids on a regular basis?
Some people with Addison’s disease, severe asthma, rheumatoid arthritis, inflammatory bowel disease and connective tissue disorders are treated with regular steroids. Steroids can increase blood glucose levels. Steroids are known to increase the post prandial blood glucose, that is blood glucose is more elevated after a meal.
If you have been on long term steroids, it is important for the dose of steroids to be doubled during the period of illness.
Please do not stop steroids, if you have been prescribed steroids by your doctor. You may need an increased dose of medications for diabetes to control blood glucose. Always discuss with your doctor or nurse the changes you need to make to get the blood glucose within target. You may have to increase the dose of insulin or blood glucose lowering tablets for the duration you are on steroids, or even may have to change the medication.
Once steroids are discontinued, you could go back to your usual diabetes medication after discussing with your doctor.
Is there any treatment or preventive medications for Coronavirus infection?
There are currently no medications or vaccines that have been approved specifically for the prevention or treatment of COVID-19. Currently these are being developed and would soon be available. People with diabetes should always have the seasonal flu vaccine.
Controlling blood glucose during infection including Coronavirus illness
Guidelines for managing people with diabetes who become unwell, also called “SICK DAY RULES”. Sick day rules are already in place in most hospitals and diabetes clinics. People with diabetes should follow the sick day rule strictly if unwell. The same rule applies to patients who are also diagnosed with COVID-19.
If you have diabetes, it is very important that you know what to do when you are ill.
When you are ill your body becomes much more resistant to the insulin you produce or taken by injection. This means that your blood glucose levels can rise and it is likely that you will need to increase your insulin dose or oral medications. You therefore need to monitor your blood glucose and ketone levels very carefully, especially if you have type 1 diabetes.
If you have type 1 diabetes, check your blood glucose at least every four hours, including during the night, and check your ketones. If your blood glucose level is high (generally 15mmol/l or 270mg/dl) or more, the target will vary from person to person or if ketones are present, follow the sick day rules and contact your diabetes team or emergency department.
Home management using sick day rules will depend on the type of illness and how you feel.
You may have a minor illness if your blood glucose is within the normal range or slightly raised with blood or urine ketones remaining negative. You could manage this at home if your blood glucose stays within the normal range. If your blood glucose is elevated and ketones are positive in your blood or urine. You may be having an infection or may not have had a proper dose of medication or insulin.
If you have type 1 diabetes, it is important to remember that when you are ill, you must monitor your blood glucose levels regularly and you should never stop taking your insulin, even if you do not feel like taking it.
Managing your diabetes, when you are ill
- If you are vomiting and not able to eat, keep sipping fluids to prevent dehydration. You should drink at least two and half litres of water a day.
- If you do not feel like eating, try to have soup, milk or ice cream.
- If your blood glucose falls below the normal range, sip sugary drinks, fruit juice, sweetened tea or have an ice lolly.
- If you feel there is an infection, contact your doctor or go to the nearest emergency department.
- If you are unable to keep fluids down and/ or cannot manage to reduce your blood glucose or ketone levels you MUST contact the hospital as an emergency.
- Adjusting your insulin doses will help to control your blood glucose levels
General Guide to Insulin Dose Adjustment
Note: This is only a general guide and may not be applicable to everyone
- Extra insulin will correct hyperglycaemia and clear ketones
- Increase ‘usual’ insulin dose by 10% if recent blood glucose is greater than 10mmol/L
- Use short acting insulin for correction of blood glucose like Fiasp, Actrapid, Novorapid, Humalog or Apidra
- Recheck blood glucose and ketones in 1-2 hours
- Repeat correction dose of insulin at intervals of 2-4 hours if required
- If you are unsure, always contact your diabetes team or emergency department.
Summary of sick day rules:
- Check blood glucose at least every four hours, including during the night especially if you have type 1 diabetes. If you do not test your blood sugar levels at home, be aware of the signs of high blood glucose.
- Ensure you are well hydrated, have plenty of unsweetened drinks, and eat small amounts at frequent intervals.
- If you have type 1 diabetes, check your ketones if your blood glucose is high, that is 15mmol/l or more, or 13mmol/l if you are using an insulin pump), If ketones are present, contact your diabetes team.
- If you are struggling to keep food down, try carbohydrates or starchy food or sweetened drinks with carbohydrates in to give you energy. Keep sipping sugary drinks or suck on glucose tablets or sweets like jelly beans. If you are vomiting, or not able to keep fluids down, immediately get medical help.
- Immediately get emergency advice if ketones are above 3.0mmol/L. Start following your hospitals SICK DAY rules if your blood ketone is more than 0.6mmol/L
If ketones are elevated (above 0.6mmol/L) and you have any of the following:
- High Blood Glucose
- Excessive thirst
- Frequent urination
- Unable to keep food/fluid down
- Abdominal pain
You will need emergency admission to the hospital to exclude diabetic ketoacidosis and treat the underlying problem/infection.
If you have type 2 diabetes and or insulin:
- If your blood glucose is less than 4mmol/l , treat as hypoglycaemia
- If your blood glucose is between 4-11mmol/l treat as normal
- If more than 11mmol/l, discuss with your doctor and follow this regime
What happens after hospitalisation?
When admitted in hospital your health care team will make appropriate changes to your medications depending on the investigations. Very sick patients who are hospitalised should be managed with insulin and medications like metformin and sodium-glucose transporter 2 inhibitors (Canagliflozin, Empagliflozin and dapagliflozin) should be discontinued.
Once you have recovered and blood glucose is stabilised, you can normally return to the medication you were on. However, the medical team may take this opportunity to help improve your overall blood glucose control and/or add on more medication to prevent diabetes related complications.
One needs to be aware that some medications for diabetes can cause side effects more so when you are unwell:
- Metformin may raise lactic acid levels
- SGLT2 inhibitors causes fluid depletion and acidosis
- GLP–1 analogues can cause nausea and vomiting
- Pioglitazones can result in fluid overload.
Prevention of Hypoglycaemia
Hypoglycaemia or “hypo” in short is when you blood glucose drops below 4mmol/l (72mg/dl). Normally when your blood glucose starts to drop, you should start feeling irritable, hungry and shaky. This usually gets better with a sugary drink followed by eating some starchy food like bread or pasta. It is important to listen to your body and correct hypoglycaemia immediately. If hypoglycaemia is not corrected, it can result in serious consequences including loss of consciousness and death. Not everyone gets a hypo. Some medications do not cause hypo. Hypo usually occurs when you have not eaten or taken a larger dose of medication/insulin to lower your blood glucose.
Some people who have experienced serious hypo, that is requiring help from paramedics are frightened of getting another one. Also, they do not want to get admitted in the hospital. During times of flu or corona virus pandemic it is always better to avoid going to hospital unless it is an emergency. However, worrying about hypoglycaemia is not good. Lot of people do worry about hypos.
Some people with diabetes, keep their blood glucose high to avoid hypoglycaemia. This obviously reduces their stress and anxiety about developing hypos. However, running a high blood glucose can increase the risk of developing complications of diabetes.
How to avoid hypoglycaemia and also avoid worrying about hypos?
In order to avoid hypoglycaemias and not be anxious about running low blood glucose, one needs to follow the rules
- Ensure you have a routine and eat at regular intervals
- Keep recording your blood glucose with time, dose of medication and food eaten
- When you have low blood glucose or symptoms of hypo, correct it immediately and document
- Analyse why you developed hypoglycaemia and how you corrected it.
- Have a clear plan for managing hypoglycaemia and keep the necessary food and drink at home, in your car/bag and work place.
- Plan ahead if you are going to change your routine.
- Do not hesitate to communicate with family, friends and colleagues about your hypoglycaemia
- Stay calm, adopt relaxation techniques
- Keep in touch with your health care team
- Always plan ahead if you are to exercise or undertake any physical activity
Top 20 tips to Manage Diabetes during illness, pandemic or isolation
- Follow your government and your doctor’s advice
- Do not panic
- Wash hands regularly and maintain social distance
- Avoid crowds and handshaking.
- Ensure at least 6-8 hours of sleep
- Keep active whilst staying at home
- Ensure you are well hydrated
- Have a balanced meal
- Stop taking SGLT 2i tablets if you become unwell, as there is an increased risk of a serious complication called Diabetic Keto acidosis (DKA). SGLT2i are tablets like Canagliflozin, Empagliflozin and Dapagliflozin.
- Ensure you check your feet regularly
- If you are unwell and seeing a health care professional, always tell them that you have diabetes.
- If you are anxious are stressed you may contact MIND (mind.org.uk) in the UK, who support people with their mental health and wellbeing at this time.
- Make sure you know how to manage the dose of your tablets /insulin you take during illness. Follow the sick day rules
- Always have emergency contact number for your health care professional or emergency service.
- Ensure you have strips to check blood glucose and ketones if you have type 1 diabetes or have poorly controlled type 2 diabetes or taking SGLT2i or sulphonylureas like gliclazide or glimepride.
- If you do not check blood glucose or do not have glucometer or test strips, be aware of the symptoms of high blood glucose, which includes tiredness, lethargy, increased thirst and frequent urge to pass urine.
- You should be well stocked with the medications, blood glucose meter, test strips and adequate sources of simple carbohydrates especially if you are on insulin and/or a sulfonylurea to prevent hypoglycaemia.
- People with diabetes should that have had all vaccinations for preventable diseases including flu vaccine.
- Communicate with family and friends and ensure they know about your diabetes
- Keep in touch with people with diabetes.
Always discuss with your doctor, nurse or emergency medical team before you make any changes to your medication unless you have an agreed sick day rule.
Please watch this video as well: https://www.youtube.com/watch?v=OiE94yA_3bE
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Dr C Rajeswaran FRCP(UK), Consultant Physician (Diabetes, Obesity & endocrinology)
Disclaimer: The content in our videos/articles are for information purposes only. It is not intended as a substitute for any advice or treatment prescribed by your doctor or health care team. Information given here should not be used for diagnosing or treating a health problem. Always consult your doctor before starting any new activity, altering dose of any medication or starting any new medication. Readers/viewers who take any advice given or gleaned in isolation that is without prior consultation with their health care provider do so at their own risk.
Declaration: It is always a good practice to declare any conflict of interest. Dr C. Rajeswaran is a director of simplyweight, simhappy and simplybariatrics. Dr Rajeswaran has been a speaker and /or attended advisory board meetings for the following pharmaceutical companies: Boehringer Ingelheim Ltd, Sanofi, MSD, Novo nordisk, Knapp, Jansen, Sunovion, Pfizer, Astra Zeneca and Eli Lilly.