Experts Issue Guidance on Concurrent COVID-19, Diabetes Treatment

Patients hospitalized for coronavirus disease 2019 (COVID-19) who have diabetes account for more than 20% of individuals admitted to intensive care units (ICUs), according to new guidance published in the Journal of Clinical Endocrinology & Metabolism.

Overall, patients with diabetes represent 25% to 34% of the patient population receiving care in ICU and non-ICU settings for COVID-19. In a manuscript published online ahead of print, researchers offer a pragmatic approach to inpatient diabetes management in light of the pandemic.

“Appropriate glycemic management contributes to a reduction in adverse clinical outcomes in acute illness,” the authors explain. However, adequate management “also requires intensive patient interactions for bedside glucose monitoring, intravenous and subcutaneous insulin administration, as well as rapid intervention for hypoglycemia events.”

Untreated hypoglycemia can result in enhanced risk of cardiac arrhythmias, increased virulence of some pathogens, and increased mortality.

Providing optimal care while adhering to social distancing measures in order to minimize contact with patients can prove challenging, especially as health care personnel face shortages of supplies and personal protective equipment (PPE).

In the inpatient setting, the use of clustered care, or coordinating tasks such as point-of-care (POC) blood glucose (BG) monitoring, meal delivery, and clinical assessment, in addition to e-consultations with glucose management teams, can decrease caregivers' exposure risks, according to the authors.

For patients with COVID-19 and well-controlled, non-insulin—treated type 2 diabetes (T2D), or those with newly recognized hyperglycemia, individuals may not require scheduled insulin therapy.

Both cohorts require POC BG monitoring with initial use of correction insulin to achieve and maintain BG between 100 and 180 mg/dL (10 mmol/L). However, “patients with persistent POC BG < 180 mg/dL (10 mmol/L) for 24 to 36 hours following admission can have the frequency of glycemic monitoring decreased to once or twice a day with discontinuation of correction insulin.”

For patients with COVID-19 who require insulin therapy, the authors outline several methods for achieving glycemic goals while minimizing contact with COVID-19 patients in non—critical care and critical care areas. Prior to the pandemic, intravenous insulin infusions were required for glycemic management in patients with critical illness.

In the wake of COVID-19, several hospitals have implemented protocols for scheduled therapy, including the following:

• More frequently dosed intermediate-acting or premix insulin preparations
• Decreased the frequency of glycemic measures to every 4 to 6 hours when infusion rates are stable
• Use of continuous glucose monitoring (CGM) for remote tracking of glycemic data
• Use of extension tubing for placement of medication infusion pumps outside a patient’s room

“It is important to note that insulin requirements can vary on a daily, if not hourly, basis in patients with critical COVD-19 infections where there is variability in insulin sensitivity over the course of the illness,” the researchers note.

Previous guidelines recommended discontinuation of noninsulin medications and initiation of insulin therapy for patients with diabetes at the time of hospital admission for COVID-19. For patients receiving non-insulin therapies, several studies demonstrated the efficacy and safety of dipeptidyl peptidase 4 inhibitors (DPP4i) sitagliptin and linagliptin in selected inpatients with T2D. However, “due to the unstable nature of acutely ill patients hospitalized with COVID-19, DPP4i are generally not recommended.”

Authors also advise against the use of saxagliptin and alogliptin as these treatments may increase incidence of heart failure. In addition, due to the absence of clinical trial supporting the use of metformin in acutely ill patients, researchers recommend current guidelines for discontinuation of metformin upon hospital entry be followed. "Insulin therapy remains the standard of care for management of hyperglycemia in patients hospitalized with COVID-19," they conclude.

When it comes to CGM vs. bedside BG monitoring, CGM does offer a potential way to facilitate care for COVID-19 patients in addition to limiting nurse exposure via reduced frequency of POC BG testing. The FDA issued temporary allowances to 2 CGM devices (Freestyle Libre [Abbott] and Dexcom G6 CGM) for in-hospital use in response to the pandemic. However, both device manufacturers recommend against using sensor data for making treatment decisions related to insulin therapy.

“Until there are studies validating their safety and efficacy in acute care setting, these CGM devices should be viewed as a supplement to and not a replacement for POC BG monitoring,” authors said.

For patients who are knowledgeable, competent, and clinically stable, experts note diabetes self-management may be appropriate. Self-management includes permitting selected patients to monitor BG and administer their own insulin.

While there are multiple drug therapies being investigated as optimal therapies for treating COVID-19 patients, according to researchers “systemic glucocorticoid therapy and hydroxychloroquine are agents with divergent but significant impact on glycemic control in patients with and without diabetes.” Additional medications used in patients with COVID-19 and diabetes can also affect BG levels, as antitussive syrups containing glucose can contribute to hyperglycemia.

“It is generally recommended that hospitals not make major changes to their current approach to managing hospitalized COVID-19 patients with hyperglycemia due to concerns that this alone can increase risk for unintended consequences requiring more time at the bedside,” researchers conclude.

Reference:

Korytkowski M, Antinori-Lent K, Drincic A, et al. A pragmatic approach to inpatient diabetes management during the COVID-19 pandemic. J Clin Endocrinol Metab. Published online June 4, 2020. doi: 10.1210/clinem/dgaa342