In This Article
- For patients with existing medical conditions or who are immunocompromised, complications from COVID-19 can be especially severe. People with diabetes are at risk for worse outcomes
- One explanation for the severe presentations could be a result of altered or impaired immune systems due to chronic inflammation
- Already published retrospective cohort studies can help inform future diabetes-specific prospective studies and clinical trials
- While technology has allowed for continuous monitoring of diabetes patients, it is important to ensure that patients without access to certain technology platforms still receive the necessary care
For patients with existing medical conditions or who are immunocompromised, complications from COVID-19 can be especially severe. In this Q&A, Janaki Vakharia, MD, clinical fellow in the Endocrinology Division at Massachusetts General Hospital, discusses the connection between COVID-19 and people with diabetes.
Q. Are people with diabetes at higher risk for catching COVID-19?
Vakharia: People with diabetes are at risk for worse outcomes, not a greater chance of contracting the virus. We do not believe they are more likely to get COVID-19 than the general population.
Q. Why are people with diabetes at higher risk for severe COVID-19 illness?
Vakharia: While we do not know the exact reason as to why patients with diabetes are experiencing more severe illness, we do know these patients tend to have more severe presentations with other viral illnesses and infections in general.
This could be a result of altered or impaired immune systems due to chronic inflammation. While there hasn't been direct research on the pathophysiology of COVID-19 and inflammation and diabetes, we can use what we've learned from other viral infections and extrapolate. Clinically, patients who have more severe COVID-19 have higher markers of inflammation. The same markers also seem to be higher in patients who have poorly controlled diabetes.
Hyperglycemia may also change the milieu within the lungs and airways and may promote viral replication or result in localized effects on immunity. Additionally, patients with diabetes often have other comorbidities such as obesity or hypertension that contribute to the severity of their disease.
Q. Is there a difference in presentation based on diabetes type?
Vakharia: It is unclear if there is a difference in presentation based on the type of diabetes, but 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, regardless the type of diabetes they have.
Poorly controlled diabetes (high HbA1c) increases the risk of severe illness and mortality. Above-target hyperglycemia has also been associated with more inflammation, which could contribute to more severe complications.
Studies have reported that patients with well-controlled diabetes during hospitalization have lower mortality. Better controlled diabetes is also associated with lower markers of inflammation, which may explain why they have better survival.
Q. Are there specific demographics within the diabetes population that are more at risk for severe COVID-19 illness than others?
Vakharia: Severe illness is prevalent among men and the elderly, although we are seeing a fair number of young adults come into the hospital.
Hispanic and Black populations seem to be disproportionately affected. This may be related to social determinants of health or other social factors. This population may have more essential workers, may be less able to physically distance due to structure of the household, or rely on public transportation. Comorbidities like obesity and hypertension are also more prevalent in these groups.
Q. Does having COVID-19 make it difficult to manage diabetes?
Vakharia: We are experiencing higher insulin requirements in patients admitted with diabetes and higher rates of diabetes complications such as diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome. We are even seeing more patients with type 2 diabetes develop DKA, although it is typically more common in patients with type 1.
The use of tube feeds and sometimes steroids in patients with severe COVID-19 also makes the management of diabetes difficult.
It is recommended that COVID-19 patients who are insulin deficient or on SLGT-2 inhibitors and managing their care at home have ketone testing kits available to monitor their levels when they are sick. They should also review their medications with their doctor to determine if any should be placed on hold temporarily.
Q. The New England Journal of Medicine recently published a letter that suggests that COVID-19 may cause new-onset diabetes cases. What has been Mass General's experience?
Vakharia: We are experiencing the same things reported in the article and have raised the same questions about the interplay between SARS-CoV-2 and diabetes.
So far, the proposed hypotheses and mechanisms are speculations and extrapolations from what we know about other viral diseases and diabetes. However, this increase in new-onset cases may support the idea that the virus may have an effect on the pancreas, leading to either transient or permanent injury.
I think the registry they are creating is a great idea and an action of collaboration to get answers to these questions.
Q. Is Mass General participating in any research studies exploring the relationship between diabetes and COVID-19?
Vakharia: At this point, we are mostly conducting retrospective cohort studies by utilizing data within the Mass General Brigham registry. We can use this data to study markers, demographics, clinical outcomes, etc. These studies can be done fairly quickly and give us some general ideas about associations. For example, diabetes with severe COVID-19 is an association, obesity and severe COVID-19 is an association.
Once you build these associations, you then want to understand what are the mechanisms driving them. While retrospective cohort studies can't prove causality, they can help inform the type of prospective clinical or basic science research needed to really understand the mechanisms as to why these associations exist.
Many of the nationwide clinical trials currently taking place are not specific to diabetes and COVID-19.
Q. Has Mass General altered any of its treatment approaches to patients with diabetes and COVID?
Vakharia: We are trying to be more conscientious about how frequently nurses need to go in to check blood sugars. We've recommended that patients bring in their own continuous glucose monitoring devices (CGM) and supplies, and have considered working with patients who are well enough to assist in their care help by having them check their own blood sugars or use their CGMs in the hospital.
In some cases, we have implemented a subcutaneous insulin protocol for patients presenting with DKA. However, this has been infrequent as subcutaneous strategies are not recommended for patients with severe DKA and/or other complicated illness (end-stage renal disease, severe acute kidney injury, pregnancy, concomitant myocardial infarction or stroke), or requiring ICU-level of care for other reasons (e.g., mechanical ventilation and/or vasopressor support, etc.).
Q. How is the Endocrinology Division managing the health of its patients during the time of virtual visits?
Vakharia: We have been able to connect with our patients virtually, either phone or video, and it has been successful. Patients have their glucometers and medications available, and we are able to discuss their care plan and provide the same level of education as we would at an in-person visit.
We utilize "data sharing" technologies that exist for blood sugar logs and CGM downloads. It can be more difficult to troubleshoot any device issues that patients may have, although video calling has helped with this too. We are also using online resources and video calling for face-to-face teachings like insulin and glucometer instruction.
While technology has helped us remain in contact with the majority of our patients, we do want to make sure that we're not excluding patients who might not have access to certain technologies. Our goal is to provide equitable care in the community, and so we've been actively reaching out to patients on cell phones or telephone landlines if they don't have video conferencing capabilities.
Q. What else should providers be mindful of during this time?
Vakharia: It's important that providers take blood sugar into consideration when providing care for COVID-19 patients. There are a lot of competing factors to consider in care—their cardiac status, respiratory status, the infectious disease component and what medications are being used for treatment. But it is becoming clear that blood sugars and the endocrine issues that are involved with COVID-19 may have just as meaningful impact on outcomes.
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