APRIL 25, 2020
Uncontrolled hyperglycemia, diabetes drive longer hospital stay, mortality in COVID-19
Adults with diabetes or uncontrolled hyperglycemia hospitalized with COVID-19 experienced a longer length of stay and markedly higher mortality compared with adults without diabetes or uncontrolled hyperglycemia, according to findings published in the Journal of Diabetes Science and Technology.
Despite growing evidence that diabetes is associated with worse COVID-19 outcomes, there remains little information on inpatient glycemic response among individuals with diabetes and acute hyperglycemia hospitalized with the novel coronavirus, David C. Klonoff, MD, FACP, FRCPE, medical director of the Mills-Peninsula Medical Center (Sutter Health) Diabetes Research Institute in San Mateo, California, and clinical professor of medicine at the University of California San Francisco, , and colleagues wrote in the study background. Additionally, a direct correlation between uncontrolled hyperglycemia and clinical outcomes has not been established, the researchers wrote.
“This was the largest study ever reported on outcomes of COVID-19 patients with diabetes and uncontrolled hyperglycemia,” Klonoff told Healio. “People with diabetes or uncontrolled hyperglycemia from 88 U.S. hospitals in ten states, who completed a hospitalization during a 37-day period, had a mortality rate of 28% compared with another COVID-19 cohort without diabetes or hyperglycemia, who had a 6% mortality rate. This represented a more than fourfold greater risk for death during an admission for COVID-19 with diabetes or hyperglycemia compared with those without these two conditions.”
Clues from point-of-care data
In a retrospective, observational study, Klonoff and colleagues analyzed data from 1,122 adults in 88 U.S. hospitals across 10 states with laboratory-confirmed COVID-19 with and without diabetes and/or acutely uncontrolled hyperglycemia, hospitalized between March 1 and April 6. HbA1c data were available for 282 adults, and 194 adults (17.3%) had diabetes. An additional 257 patients had uncontrolled hyperglycemia, defined as at least two blood glucose readings above 180 mg/dL within any 24-hour period, using information from Glytec, an insulin software titration company based in Waltham, Massachusetts, that maintains patient glycemic data from contracted hospitals for lab-confirmed COVID-19 cases.
“Point-of-care blood glucose test results are transmitted and stored for all patients on contracted hospital units,” the researchers wrote. “In this study, we identified COVID-19 inpatients from the Glytec data warehouse treated during a 37-day period and analyzed all transmitted blood glucose during their hospital stay. We then characterized the COVID-19 patients from our contracted hospitals according to their clinical characteristics at hospital presentation, inpatient glycemic control and clinical outcomes.”
Compared with adults without diabetes or uncontrolled hyperglycemia, the 451 adults with diabetes and/or uncontrolled hyperglycemia were more likely to be men (53% vs. 59%; P = .035) and were older (mean age, 61 years vs. 65 years; P = .005). Individuals in the diabetes and uncontrolled hyperglycemia group had higher rates of hyperglycemia at admission vs. those without diabetes or hyperglycemia (mean blood glucose, 202 mg/dL vs. 114 mg/dL; P < .001) and were more likely to have renal dysfunction (40.6% vs. 23.5%; P < .001).
The diabetes and uncontrolled hyperglycemia group spent 3,885 patient days in the hospital vs. 3,793 patient days for those without diabetes or hyperglycemia. Those with diabetes and/or hyperglycemia spent 37.8% of patient days with a mean blood glucose above 180 mg/dL compared with 25.8% for adults without diabetes or hyperglycemia.
At the time researchers conducted the analysis, 552 adults remained hospitalized; among 570 discharged patients, 77 died, for a mortality rate of 13.5%.
Of the 77 individuals who died, 53 had combined diabetes and uncontrolled hyperglycemia (28.8%) compared with 24 who did not have diabetes or uncontrolled hyperglycemia (6.2%; P < .001).
Among the 493 adults discharged who survived, the combined diabetes and uncontrolled hyperglycemia group (n = 131) experienced a longer median length of stay vs. those without diabetes or hyperglycemia (mean, 5.7 days vs. 4.3 days; P < .001).
“The study also demonstrated that during a hospitalization for COVID-19, the presence of diabetes or hyperglycemia was associated with a longer hospitalization and slightly worse kidney function,” Klonoff said. “The median length of stay was longer among patients with diabetes and/or uncontrolled hyperglycemia compared with patients without diabetes or hyperglycemia.
Next steps for management
The researchers noted that the findings raise two important questions: whether the high rates of death from COVID-19 in the study are predominantly due to metabolic derangements with associated sequelae, and whether acute hyperglycemia plays a role that can be ameliorated through effective glycemic management.
“The next step I am working on is to further analyze the database to determine whether COVID-19 patients with diabetes and uncontrolled hyperglycemia, who were better controlled in the hospital, compared with those with worse control, had better outcomes,” Klonoff said. “It will also be of interest if it turns out that patients who arrived with high glucose levels and eventually were treated to the point of achieving target blood glucose levels had better outcomes than those who arrived with elevated blood glucose levels that persisted throughout hospitalization. If an association between achievement of target glycemia — following initial hyperglycemia — with greater survival is demonstrated, then that observation will inspire hospitalists to vigorously treat elevated admission glucose levels for patients with diabetes and uncontrolled hyperglycemia to lower the glucose concentrations and also decrease the risk for death.” – by Regina Schaffer