What We Know About Patients with Diabetes or Hyperglycemia and COVID-19
Why Glycemic Control is Important:
It has been widely studied that the incidence of diabetes predisposes patients to an increased risk of infections1 and an increased risk of complications during infection2. Additionally, the occurrence of hyperglycemia contributes to an impaired immune response.3
Emerging Studies on COVID-19 and Patients with Glycemic Control Issues Suggest:
- Patients with diabetes appear to be at risk for worse outcomes with COVID-19.4,5,8
- Patients with diabetes have an increase in mortality when infected with COVID-19.4,6-10
- Stress hyperglycemia in the hospital is known risk factor for worse outcomes.24,25
- Our recent work with patients with Covid-19 confirms that this applies to this group of patients as well. Patients designated as uncontrolled hyperglycemia (but with no apparent history of diabetes) had a mortality rate at 42% compared with the 15% mortality in the population of patients with diabetes. This is a mortality rate seven times higher than the population of patients without diabetes or hyperglycemia (6%).26
- There is a greater incidence in patients with diabetes in the intensive care unit (ICU) compared to those without the preexisting condition8,10
- Physiological factors, such as the increased expression of ACE-2 receptors in patients with diabetes, may potentially increase the susceptibility of patients to COVID-19 infection7
Focus on Basic Glycemic Management Best Practices
Standard Recommendations for Patients That Need Insulin Therapy:
- Insulin should be used for the majority of hospitalized patients with hyperglycemia11,12,16
- Continuous intravenous insulin infusion should be utilized to treat persistent hyperglycemia for critically ill patients11,15, 17, 18-20, 23
- Intravenous insulin infusions should be administered based on validated written or computerized protocols that allow for predefined adjustments in the infusion rate, account for glycemic fluctuations and achieve low rates of hypoglycemia11-14,18,19,21,22
- Use of only a sliding scale insulin regimen in the inpatient hospital setting is strongly discouraged12,16
- A basal insulin or a basal plus bolus correction insulin regimen with mealtime adjustments as warranted is preferred to treat noncritically ill hospitalized patients13,16
- Transition patients to subcutaneous insulin schedules using institutional protocols before discontinuing intravenous insulin infusions12,16,17,22
How Glytec Can Help
Existing Glytec Customers:
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COVID-19 Provider Resources
- SHM Resources
- ACP Resources, and Annals IM
- SCCM Resources
- CDC COVID-19
- CDC Publications
- Interactive Johns Hopkins coronavirus map
- WHO Situation Reports
- SCCM online resources for the Non-ICU Clinician
- Pubmed’s LitCovid with information specific to diabetes
- WHO’s COVID19 research database
- Muller LM, Gorter KJ, Hak E, Goudzwaard WL, Schellevis FG, Hoepelman AI, et al. Increased risk of common infections in patients with type 1 and type 2 diabetes mellitus. Clin Infect Dis. 2005;41:281–8.
- Miller AC, Subranian RA, Safi F, Sinert R, Zehtabchi S, Elamin EM. Influenza A 2009 (H1N1) virus in admitted and critically ill patients. J Intensive Care Med. 2011;27:25–31
- Geerlings SE, Hoepelman AI. Immune dysfunction in patients with diabetes mellitus (DM) FEMS Immunol Med Microbiol. 1999;26:256–65.
- Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. Published online February 24, 2020. doi:10.1001/jama.2020.2648.
- Ruan Q, Yang K, Wang W, Jiang L, Song J. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China [published online ahead of print, 2020 Mar 3]. Intensive Care Med. 2020;1–3. doi:10.1007/s00134-020-05991-.
- Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study [published correction appears in Lancet. 2020 Mar 28;395(10229):1038] [published correction appears in Lancet. 2020 Mar 28;395(10229):1038]. Lancet. 2020;395(10229):1054–1062. doi:10.1016/S0140-6736(20)30566-3)
- Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? [published online ahead of print, 2020 Mar 11]. Lancet Respir Med. 2020;S2213-2600(20)30116-8. doi:10.1016/S2213-2600(20)30116-8)
- Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China [published correction appears in Lancet. 2020 Jan 30;:]. Lancet. 2020;395(10223):497–506. doi:10.1016/S0140-6736(20)30183-5
- Onder G, Rezza G, Brusaferro S. Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy. JAMA. Published online March 23, 2020. doi:10.1001/jama.2020.4683
- Guan WJ, Ni ZY, Hu Y, et al. Clinical Characteristics of Coronavirus Disease 2019 in China [published online ahead of print, 2020 Feb 28]. N Engl J Med. 2020;0:NEJMoa2002032. doi:10.1056/NEJMoa2002032
- American Association of Clinical Endocrinologists. AACE.com. https://www.aace.com/disease-state-resources/diabetes/depth-information/management-hyperglycemia-critical-care-setting. Accessed April 9, 2020.
- Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2020. American Diabetes Association Diabetes Care Jan 2020, 43 (Supplement 1) S193-S202; DOI:2337/dc20-S015
- Jacobi et al. Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Critical Care Medicine: December 2012 - Volume 40 - Issue 12 - p 3251-3276 doi: 10.1097/CCM.0b013e3182653269
- Shankar-Hari M, Phillips GS, Levy ML, et al. Developing a New Definition and Assessing New Clinical Criteria for Septic Shock: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):775–787. doi:10.1001/jama.2016.0289
- Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med. 2017;45(3):486–552. doi:10.1097/CCM.0000000000002255
- Gosmanov AR, Gosmanova EO, Dillard-Cannon E. Management of adult diabetic ketoacidosis. Diabetes Metab Syndr Obes. 2014;7:255–264. Published 2014 Jun 30. doi:10.2147/DMSO.S50516
- Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. 2009. Hyperglycemic crises in adult patients with diabetes. Diabetes Care, 32(7): 1335‐
- Ullal J, Aloi JA, Reyes-Umpierrez D, et al. Comparison of Computer-Guided Versus Standard Insulin Infusion Regimens in Patients With Diabetic Ketoacidosis. J Diabetes Sci Technol 2018; 12(1): 39-46. [http://dx.doi.org/10.1177/1932296817750899] [PMID: 29291648]
- Lazar et al. The Society of Thoracic Surgeons practice guideline series: Blood glucose management during adult cardiac surgery.Ann Thorac Surg. 2009 Feb;87(2):663-9. doi: 10.1016/j.athoracsur.2008.11.011.
- Ian Blumer, Eran Hadar, David R. Hadden, Lois Jovanovič, Jorge H. Mestman, M. Hassan Murad, Yariv Yogev, Diabetes and Pregnancy: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 98, Issue 11, 1 November 2013, Pages 4227–4249, https://doi.org/10.1210/jc.2013-2465
- Aloi J, Bode BW, Ullal J, et al. Comparison of an electronic glycemic management system versus provider-managed subcutaneous basal bolus insulin therapy in the hospital setting. J Diabetes Sci Technol 2017; 11(1): 12-6. [http://dx.doi.org/10.1177/1932296816664746] [PMID: 27555601]
- Umpierrez GE, Hellman R, Korytkowski MT, Kosiborod M, Maynard GA, Montori VM, et al. 2012. Management of hyperglycemia in hospitalized patients in non‐critical care setting: an Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology and Metabolism. 97(1);16‐
- Umpierrez GE, Cuervo R, Karabell A, Latif K, Freire AX, Kitabchi AE. Treatment of diabetic ketoacidosis with subcutaneous insulin aspart. Diabetes Care. 2004;27(8):1873–1878. doi:10.2337/diacare.27.8.1873
Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87(3):978–982. doi:10.1210/jcem.87.3.8341
Olariu E, Pooley N, Danel A, Miret M, Preiser JC. A systematic scoping review on the consequences of stress-related hyperglycaemia. PLoS One. 2018;13:e0194952.
- Bode B, Garrett V, Messler J, McFarland R, Crowe J, Booth R, Klonoff DC. Glycemic Characteristics and Clinical Outcomes of COVID-19 Patients Hospitalized in the United States. J Diabetes Sci Technol. 2020; In press.