The Links Between COVID-19 – Diabetes, Know and Unknown

Dr. Rajesh Jain May 11, 2020 22

covid19

The Links Between COVID-19 – Diabetes, Know and Unknown

COVID-19 is a new and potentially serious coronavirus. The World Health Organization (WHO) has declared the COVID-19 outbreak a public health emergency of international concern. Over 23 million people around the world have been known to be infected.

There are many coronaviruses, ranging from the common cold to much more serious viruses such as Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS). They are viruses that have been transmitted from animals to people. In severe cases, coronaviruses can cause infection in the lungs (pneumonia), kidney failure, and even death. At present, there is no vaccine against COVID-19.

Common signs are typical flu-like symptoms: a fever, cough, breathing difficulties, tiredness, and muscle aches. Symptoms usually start within 3-7 days of exposure to the virus, but it has taken up to 14 days for symptoms to appear in some cases.

People of all ages can be infected. For many (more than 80% of cases), COVID-19 is mild, with minimal flu-like symptoms. Some have not shown symptoms or only very mild symptoms, more like a common cold. The majority of people who have caught the virus have not needed to be hospitalized for supportive care. However, in up to 15% of cases, COVID-19 has been severe, and in around 5% of cases, it has led to critical illness. The vast majority (around 98%) of people infected to date have survived.

Older people and people with pre-existing medical conditions (such as diabetes, heart disease, and asthma) appear to be more vulnerable to becoming severely ill with the COVID-19 virus. When people with diabetes develop a viral infection, it can be harder to treat due to fluctuations in blood glucose levels and, possibly, the presence of diabetes complications.

There appear to be two reasons for this. Firstly, the immune system is compromised, making it harder to fight the virus and likely lead to a longer recovery. Secondly, the virus may thrive in an environment of elevated blood glucose.

Like any other respiratory disease, COVID-19 is spread through air droplets dispersed when an infected person talks, sneezes, or coughs. The virus can survive from a few hours up to a few days, depending on the environmental conditions. It can be spread through close contact with an infected person or by contact with air droplets in the environment (on a surface, for example) and then touching the mouth or nose (hence the common advice circulating on hand hygiene and social distancing).

COVID-19 is a new coronavirus. Keep informed of the latest developments by looking out for updates and advice from your government, the national diabetes association, and other reliable sources.

IDF has joined a global effort, together with the world’s leading diabetes organizations, to reduce the risk for people with diabetes during the COVID-19 pandemic. Learn more.

Scroll down further for advice and useful links on the management and prevention of COVID-19 in people with diabetes.

The story of COVID-19 and the science behind the pandemic is evolving rapidly every day, with a flurry of publications in various clinical and preclinical journals.

Here, I summarize the known and unknown links between diabetes and COVID-19, focusing on three pertinent clinical questions.

How does diabetes affect the risk of COVID-19 infection? Just as with other respiratory illnesses, such as influenza A, it appears that diabetes increases the risk for COVID-19 infection, although no prevalence studies comparing people with and without diabetes for COVID-19 have been published to support this presumption.

Several studies from China, Italy, and the United States suggest that diabetes increases risks for severe COVID-19 complications and mortality. In one Chinese study, people with diabetes had the second-highest fatality rate (7.3%) after cardiovascular disease (CVD; 10.5%) among those with comorbid conditions.

Although several questions regarding mechanisms responsible for increased severity of COVID-19 with diabetes need to be investigated (immune dysfunction, link to co-morbidities such as hypertension or obesity, link to complications such as CVD or nephropathy), the single most important outstanding clinical question in my mind is: What are the role of achieving euglycemia in COVID-19 infection and its severity? That is, does improving glucose control (chronically in an outpatient setting or acutely in an inpatient setting) result in primary prevention of COVID-19 infection or reduce its complications and fatality?

A recent data analysis for hospitalized patients with COVID-19 suggested a much higher mortality rate. It increased the length of stay among those who developed hyperglycemia during their hospital stay but had no evidence of diabetes before being admitted. Similarly, a previous publication had found an independent association between fasting glucose at hospital admission and the severity of H1N1.

The question that needs to be explored further in type 1 and type 2 diabetes is whether acute hyperglycemia is truly an independent causal factor or simply a marker for increased severity and mortality from COVID-19.

Additional investigations into the efficacy (or at least safety) of common diabetes medications about COVID-19 infection would be of clinical interest. Specifically, ACE2 and DPP-4 have been identified as receptors for the coronavirus and a related virus. Some reassurance on the safety of ACE inhibitors and angiotensin receptor blockers with COVID-19 hospitalizations is provided by recent retrospective study publications.

How COVID-19 Impacts People with Diabetes

This information is based on current knowledge of COVID-19 and will be updated as additional scientific evidence is released.

We know you have questions. We have answers.

COVID-19 and Diabetes

Q: Are people with diabetes more likely to get COVID-19?

A: There is not enough data to show whether people with diabetes are more likely to get COVID-19 than the general population. The problem people with diabetes face is they’re more likely to have worse complications if they get it, the not greater chance of getting the virus. Also, the more health conditions someone has (for example, diabetes plus heart disease) adds to their risk of getting those serious complications from COVID-19. Older people are also at higher risk of complications if they get the virus.

While the death toll is rising as the virus spreads, we expect the death rate—the number of people who die from the virus—to go down as we get better at detecting and treating it.

Q: Do people with diabetes have a higher chance of serious complications from COVID-19?

A: People with diabetes are more likely to have serious complications from COVID-19. In general, people with diabetes are more likely to have more severe symptoms and complications when infected with any virus.

Your risk of getting very sick from COVID-19 is likely to be lower if your diabetes is well-managed. Having heart disease or other complications in addition to diabetes could worsen the chance of getting seriously ill from COVID-19, like other viral infections, because more than one condition makes it harder for your body to fight the infection.

Viral infections can also increase inflammation, or internal swelling, in people with diabetes. Above-target blood sugars can also cause this, and that inflammation could contribute to more severe complications.

Q: Are the risks different for people with type 1 and type 2 diabetes?

A: The CDC is continuing to update its website as new information about COVID-19 becomes available. Currently, they are reporting that people of any age with certain underlying medical conditions, including type 2 diabetes, are at increased risk of severe illness from COVID-19.

Based on what the CDC is reporting at this time, people with type 1 or gestational diabetes might be at an increased risk for severe illness from COVID-19. Because COVID-19 is a new disease, we don’t know as much as we’d like to about how underlying medical conditions increase the risk for severe illness from COVID-19.

It’s important to remember that people with either type of diabetes can vary in their age, complications they’ve developed, and how well they have been able to manage their diabetes. People who already have diabetes-related health problems are likely to have worse outcomes if they contract COVID-19 than people with diabetes who are otherwise healthy, whichever type of diabetes they have.

Q: Do I need to worry about DKA (diabetic ketoacidosis)?

A: When sick with a viral infection, people with diabetes face an increased risk of diabetic ketoacidosis (DKA), commonly experienced by people with type 1 diabetes.

DKA can make it challenging to manage your fluid intake and electrolyte levels—which is important in managing sepsis. Sepsis and septic shock are some of the more serious complications that some people with COVID-19 have experienced.

Learn the signs of diabetic ketoacidosis (DKA), and be sure to talk with your diabetes care team about when to check for ketones and when to contact your doctor if you have them. And if you are sick, know what to do.

Q: Does COVID-19 cause diabetes?

A: We don’t yet have evidence as to whether COVID-19 would contribute to the onset of diabetes.

Risks and Warning Signs

Q: Is COVID-19 different from the seasonal flu?

A: COVID-19 is proving to be a more serious illness than seasonal flu in everyone, including people with diabetes. All of the standard precautions to avoid infection that has been widely reported are even more important when dealing with this virus.

We encourage people with diabetes to follow the guidance of the CDC to be sure you’re doing everything you can to protect yourself and others. As always, people with diabetes should get a flu shot this year, although it’s important to understand the flu vaccine will not protect against COVID-19.

Q: What are the symptoms and warning signs I should be watching out for?

A: People with COVID-19 have reported a wide range of symptoms, ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. Pay attention for potential COVID-19 symptoms, including:

Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea

Q: What should I do if I think I’m developing symptoms of COVID-19?

A: If you feel like you are developing symptoms, call your doctor.

When you call:

Have your glucose reading available
Have your ketone reading available
Keep track of your fluid consumption (you can use a 1-liter water bottle) and report.
Be clear on your symptoms (for example: are you nauseated? Just a stuffy nose?)
Ask your questions on how to manage your diabetes

Q: What are the emergency warning signs—and what should I do if I’m experiencing them?

A: If you develop emergency warning signs for COVID-19, get medical attention immediately. In adults, emergency warning signs include:

Difficulty breathing or shortness of breath
Persistent pain or pressure in the chest
New confusion
Inability to wake or stay awake
Bluish lips or face

Precautions

Q: What should I do to prevent the spread of COVID-19 in my home?

A: For people with underlying health conditions, including diabetes, healthy family members in the household should take steps as if they were a significant risk to them. For example, they should be sure to:

Cover their nose and mouth with a mask any time they have to leave home.
Wash their hands frequently, especially before feeding or caring for the vulnerable person.
Stay at least 6 feet from people who don’t live in their household.

Learn more about protecting yourself and others here.

Q: What should I do if someone in my household tests positive for COVID-19?

A: If a member of your household is sick, be sure to give them their own room, if possible, and keep the door closed. Have only one family member care for them, and consider providing additional protections or more intensive care for household members over 65 years old or with underlying health conditions. Learn more about how to keep your home safe here.

COVID-19 and Insulin Accessibility

Q: Will COVID-19 impact my access to insulin and other diabetes supplies?

A: Leading manufacturers are reporting that COVID-19 is not impacting their current manufacturing and distribution abilities for insulin and other supplies at this time. We are continuing to monitor the situation and will provide updates should anything change. If you are struggling to pay for insulin or know someone who is, the ADA has resources to help—visit InsulinHelp.org.

COVID-19 in Hospital Settings

Q: Can patients self-test use blood glucose meters labeled for home use while they are in the hospital during the COVID-19 pandemic?

A: Yes. The FDA recognizes that home-use blood glucose meters may be an option to provide relief and support to health care professionals in hospital settings seeking to reduce interactions between patients and health care providers, thereby limiting exposure to COVID-19, and conserving personal protective equipment (PPE), whenever possible.

In addition, some home-use blood glucose meters have built-in wireless data transmission capabilities, which can facilitate remote patient monitoring. Therefore, the FDA encourages hospitals to consider policies to allow patients to self-test using home-use blood glucose meters, including using patients’ own home-use blood glucose meters or providing a home-use blood glucose meter when patients are admitted to the hospital. Using strategies where patients in the hospital may check their own blood glucose while allowing wireless access to results by health care professionals may limit the direct contact and reduce the risk of passing on the virus preserve PPE.

Q: What factors do healthcare providers caring for a COVID-19 patient consider before allowing patients to self-test using a home-use blood glucose meter?

A: In considering whether patients should check their own blood glucose using a home-use blood glucose meter, health care providers caring for COVID-19 patients will take into consideration the availability of other equipment in their hospitals to get timely and accurate blood glucose readings that can be easily transferred or logged into the patient’s medical record. Health care providers will also consider whether the patient is well enough to conduct their own self-testing properly and is comfortable using a new type of home-use blood glucose meter if the hospital provided one. While a patient may be used to getting blood glucose readings using their own meter, they may not be as successful using an unfamiliar model.

Q: Can COVID-19 patients with diabetes bring their own blood glucose monitors to the hospital if they need to be hospitalized?

A: Yes. Self-management of diabetes by a patient using their own devices, even in a hospital setting, is consistent with device labeling.

Q: If a hospital chooses to dispense home-use blood glucose meters to in-patients, can that meter be used for multiple patients?

A: No. All blood glucose meters labeled “for single patient use only,” whether provided by the hospital to a patient or brought into a hospital by a patient, may only be used by the patient. Blood glucose meters labeled “for single patient use only” may not be shared among multiple patients. This limitation is necessary to prevent transmission of infection between individuals as these types of glucose meters are not robust enough to withstand the cleaning and disinfection needed for more than one patient to use them. Any home-use blood glucose meter given to a patient should either be taken home by that patient or disposed of when the patient is discharged from the hospital.

Q: Can disinfectants be ingested as a preventive measure?

A: No, people should not consume or misuse disinfectants. According to the CDC, household cleaners and disinfectants can cause health problems when not used properly. Follow the instructions on the product label to ensure safe and effective use.

COVID-19 and Work

Q: I live with diabetes. Is it safe for me to work during the pandemic?

A: The answer depends on many factors related to both your health and your particular job. The type of work you do and whether you can reduce risk by wearing PPE, working behind a plexiglass shield, working outside, or staying far away from others will be all factors into your risk of exposure. The ADA recommends that you consult with your diabetes care team to make your decision. For more information on your risk and your options, visit our FAQ for Workers. For employment resources, including a sample physician letter requesting reasonable accommodations and a letter to employers, visit our Know Your Rights: COVID-19 page.

Q: I live with diabetes, and I am afraid of getting seriously ill from COVID-19. What are my rights at work?

A: As a person with diabetes, you have several rights under federal laws. For more information about those rights, visit our Know Your Rights: COVID-19 page.

Q: What is reasonable accommodation?

A: A reasonable accommodation is defined as any change to the application or hiring process, to the job, to the way the job is done, or the work environment that allows a person with a disability who is qualified for the job to perform the essential functions of that job or enjoy equal employment opportunities. As the name implies, reasonable accommodations must be reasonable, which means they cannot pose an undue hardship on your employer. Learn more about reasonable accommodations in the American Diabetes Association’s Reasonable Accommodations fact sheet.

Q: What are my options for reasonable accommodations?

A: Options vary based on an individual’s job functions and may change over the course of the pandemic. For some examples of common accommodations that people with diabetes are requesting, visit our FAQ for Workers.

Q: My job cannot be done with telework. Do I have any other options for reasonable accommodations?

A: If you cannot telework, you can explore the other options discussed in our FAQ for Workers with your employer and ask if they have any additional suggestions for accommodations.

Venturing Out Amid COVID-19

Q: Businesses have begun to re-open in my community. Does that mean it’s safe to go out?

A: As communities and businesses continue to open, many people are looking for ways to resume some daily activities while staying as safe as possible. While there is no way to eliminate the risk of infection, understanding the potential risks and prevention measures available will help you protect yourself and reduce the spread of COVID-19.

The risk of an activity depends on many factors, especially for those with an increased risk of severe illness. These include:

Is COVID-19 spreading in your community?
Will you have potential close contact with someone who is sick or not wearing a mask (and maybe asymptomatic)?
Do you take everyday actions to protect yourself from COVID-19?

In addition, risk levels vary dramatically depending on the specific activity and community. That’s why you need to consider your own personal situation and the risk for you, your family, and your community before venturing out. The CDC provides additional guidance here.

Q: Are there ways to reduce the risk of COVID-19 when going out?

A: In general, the more closely you interact with others, and the longer that interaction, the higher the risk of COVID-19 spread. Activities are safer if:

You can maintain at least 6 feet of space between you and others. COVID-19 spreads more easily between people who are within 6 feet of one another.
They are held in outdoor spaces. Indoor spaces with less ventilation are riskier and often make it harder to stay apart from other people.
People are wearing masks. Interactions where one or more people aren’t wearing masks, create increased risk.

Additional guidance on reducing risk can be found here.

If COVID-19 is spreading in your community, take extra measures to distance yourself and other people to further reduce your risk of being exposed to this new virus. Stay home as much as possible.

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Dr. Rajesh Jain

Dr. Rajesh Jain MD PG Diploma Diabetes, UK

The diabetesasia is the advocate for the people currently living with diabetes Burden & NCDs Risk. Global Diabetes Walk campaign remind us to Prevent diabetes.

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