APRIL 20, 2020

Miriam E. Tucker

Study: Pay Attention to In-Hospital Glucose to Save Lives in COVID-19

Diabetes and hyperglycemia among people without prior diabetes are strong predictors of mortality among hospitalized patients with COVID-19, new research suggests.

The data suggest that although glycemic control may not be at the forefront of most clinicians' minds when it comes to COVID-19, it is important, and paying more attention to it could save lives, say the researchers, led by Bruce Bode, MD, of Atlanta Diabetes Associates, Georgia, and colleagues, including employees of Glytec, an insulin management software company.

The results were published online April 17 in the Journal of Diabetes Science and Technology.

In the observational study of more than 1000 inpatients with COVID-19 at US hospitals between March 1 and April 6, 2020, those with diabetes and those with hyperglycemia throughout their stay had a fourfold greater inpatient mortality than those without diabetes or hyperglycemia.

And for those without evidence of diabetes prior to admission who developed hyperglycemia in hospital, mortality was sevenfold greater.

This is the first published report characterizing glycemic control among patients hospitalized with COVID-19 in the United States.

"The coronavirus outbreak has stretched our hospitals and health systems to a point we've never experienced before, so it's understandable that glycemic management may not have been a major point of focus thus far," said Bode, an advisory board member for Glytec, in a statement.

"This research confirms that diabetes is an important risk factor for dying from COVID-19."

"It also suggests that patients with acutely uncontrolled hyperglycemia — with or without a diabetes diagnosis — are dying at a higher rate than clinicians and hospitals may recognize," he added.

Therefore, Bode and colleagues write, "in the absence of evidence to the contrary, clinicians should interpret COVID-19 associated hyperglycemia as a potential indicator of pancreatic islet cell injury and a risk for poor outcome."

"Clinicians should treat hyperglycemia to achieve [blood glucose] targets < 180 mg/dL for most patients. This equates to basal–bolus insulin therapy in most non-ICU patients and continuous insulin infusion in the critically ill as directed by national guidelines," they add.

Dysglycemia Predicts Mortality, Longer Hospital Stay

The study involved 1122 patients with COVID-19 at 88 hospitals in 11 representative US states. A1c data was available for 282 patients.

There were 194 patients with diabetes (A1c > 6.5%) and another 257 patients with "uncontrolled hyperglycemia," defined as two or more blood glucose readings above 180 mg/dL during any 24-hour period, either with an A1c < 6.5% ("stress hyperglycemia") or no A1c testing during hospitalization.

Compared to the 671 patients without diabetes or uncontrolled hyperglycemia, the 451 patients with one or the other were more likely to be male (59% vs 53%; P = .035) and were older (65 vs 61 years; P = .005).

On admission, mean blood glucose levels were 202 mg/dL in the diabetes/uncontrolled hyperglycemia group versus 114 mg/dL in those without either (P < .001). Renal dysfunction (estimated glomerular filtration rate < 60 mL/min) was also more common in the former (40.6% vs 23.5%; P < .001).

At the time of analysis, 552 patients were still hospitalized and 570 patients were "inactive" (had been discharged or died).

Of the inactive group, 77 patients (13.5%) had died; 53 patients were in the diabetes/uncontrolled hyperglycemia group (28.8%) compared to 24 patients (6.2%) with neither diabetes or hyperglycemia (P < .001).

Among the 493 patients who survived to discharge, the diabetes/uncontrolled hyperglycemia group also had significantly longer median hospital stays (5.7 days) compared to those without diabetes or hyperglycemia (4.3 days).

Outcomes Worse for Those Without a Previous Diabetes Diagnosis

In a further subset analysis, death rates were considerably higher among those with uncontrolled hyperglycemia, at 41.7%, compared to those admitted with a diabetes diagnosis, at 14.8% (P < .001).

And those with uncontrolled hyperglycemia spent longer in hospital than those with diabetes, whether they died there or were ultimately discharged (both P < .001).

The reason for this is not clear, but hospital staff may overlook high blood glucose readings in patients who don't arrive with a diabetes diagnosis, especially in the current pandemic crisis situation.

Speaking to Medscape Medical News about hospital care for patients with COVID-19 and dysglycemia, Irl B. Hirsch, MD, of the University of Washington, Seattle, said: "I see this all the time."

Patients "go into the hospital for a different reason and have a random glucose of 300 mg/dL, but in many hospitals they only do routine point-of-care glucose testing if they come in with a diagnosis of diabetes. That's a huge problem."

Bode and colleagues agree, and reiterate: "We recommend health systems ensure inpatient hyperglycemia is safely and effectively treated."

Bode is an advisory board member for Glytec, and five coauthors are company employees. Hirsch consults for Abbott Diabetes Care, Roche, and Bigfoot Biomedical, conducts research for Medtronic, and is a diabetes editor on for UpToDate.

View on Medscape

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