Spotlight on COVID-19 and diabetes

Experts gave advice on which diabetes drugs should be stopped in patients with COVID-19, and studies highlighted associations between the two diseases.

Recent articles offered tips on treatment of patients with diabetes and COVID-19, as well as data on their outcomes.

Recommendations on management of diabetes during the pandemic were offered by a personal view article published by The Lancet Diabetes & Endocrinology on April 23. The group of authors reviewed the potential links between diabetes and COVID-19 and suggested optimizing glycemic control to help patients with diabetes avoid the disease. For patients who do develop severe COVID-19, they recommended discontinuing metformin and sodium-glucose cotransporter-2 inhibitors to reduce the risks of lactic acidosis or diabetic ketoacidosis, respectively. “Importantly, discontinuing these drugs is not recommended prophylactically for out-patients with diabetes without any symptoms of infection or in the absence of evidence for a serious course of COVID-19,” the authors said. They noted that dipeptidyl peptidase-4 inhibitors do not need to be discontinued. If diabetes drugs are discontinued, insulin is the alternative treatment of choice and, in cases requiring large amounts of insulin, IV infusion is recommended, the authors said.

Three studies analyzed outcomes among patients with diabetes and COVID-19. First, a single-center observational study, published by BMJ Open Diabetes Research & Care on April 27, looked at 193 Chinese patients with severe COVID-19, 48 of them with diabetes. Compared to the patients without diabetes, they were older, were more likely to undergo mechanical ventilation or ICU admission, and had higher levels of inflammatory markers. The Kaplan-Meier survival curve showed a trend toward poorer survival in patients with diabetes, with a hazard ratio of 1.53 (95% CI, 1.02 to 2.30; P=0.041) after adjustment for age, sex, hypertension, cardiovascular disease, and cerebrovascular disease. Next, a systematic review and meta-analysis, published by Diabetes & Metabolic Syndrome: Clinical Research & Reviews on April 17, looked at 6,452 COVID-19 patients from 30 studies and found that diabetes was associated with significantly higher risk of mortality (risk ratio [RR], 2.12; 95% CI, 1.44 to 3.11; P<0.001), severe disease (RR, 2.45; 95% CI, 1.79 to 3.35; P<0.001), acute respiratory distress syndrome (RR, 4.64; 95% CI, 1.86 to 11.58; P=0.001), and disease progression (RR, 3.31; 95% CI, 1.08 to 10.14; P=0.04), but not ICU admission. However, another review of 1,382 patients from eight studies found a significantly increased risk of its primary outcome, ICU admission, associated with diabetes (odds ratio [OR], 2.79; 95% CI, 1.85 to 4.22; P<0.0001). Mortality risk, the secondary outcome, was also significantly increased with diabetes (OR, 3.21; 95% CI, 1.82 to 5.64; P<0.0001), according to the results published by the Journal of Clinical Virology on April 9.

Another study, published as a brief report in Diabetes, Obesity and Metabolism on April 20, found that COVID-19 may cause ketosis or ketoacidosis in patients with and without diabetes. Of 658 patients with COVID-19, 42 presented with ketosis on admission with no obvious fever or diarrhea. Compared to the group as a whole, they were younger and had greater prevalence of fatigue, diabetes, and digestive disorders. The patients with ketosis also had longer length of stay (19.0 vs. 16.0 days; P<0.001) and higher mortality rate (21.4% vs. 8.9%; P=0.017). The authors recommended that clinicians “pay attention to COVID-19 patients with ketoacidosis, especially those with diabetes, in order to reduce the associated mortality from complications of COVID-19.”

Finally, an article published by Endocrine Reviews on April 15 covered the basic and clinical science supporting shared pathways of diabetes, coronavirus infections, and receptors of angiotensin-converting enzyme 2 and dipeptidyl peptidase-4.