What expert panel recommendations have been put forward on the management of diabetes mellitus (DM) in patients with coronavirus disease 2019 (COVID-19)?

Updated: Sep 27, 2021
  • Author: Romesh Khardori, MD, PhD, FACP; Chief Editor: George T Griffing, MD  more...
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Answer

Recommendations for the management of diabetes in patients with COVID-19 were published on April 23, 2020, by an international panel of diabetes experts. [407, 408]

Regarding infection prevention and outpatient care:

  • Patients with diabetes, particularly those with type I diabetes mellitus, should be sensitized to the importance of optimal metabolic control
  • Current therapy should, if appropriate, be optimized
  • Telemedicine and connected health models should be used, if possible, to maintain maximal self-containment

All patients hospitalized with COVID-19 should be monitored for new-onset diabetes.

Regarding management in the intensive care unit (ICU) of infected patients with diabetes:

  • Plasma glucose monitoring, electrolytes, pH, blood ketones, or β-hydroxybutyrate
  • There is liberal indication for early intravenous insulin therapy in severe disease courses (acute respiratory distress syndrome, hyperinflammation) for exact titration, with variable subcutaneous resorption avoided, and management of commonly encountered very high insulin consumption

Therapeutic goals include the following:

  • Plasma glucose concentration: 4-8 mmol/L (72-144 mg/dL) for outpatients or 4-10 mmol/L (72-180 mg/dL) for inpatients/intensive care, with, for frail individuals, the lower value possibly adjusted upward to 5 mmol/L (90 mg/dL)
  • A1c < 53 mmol/mol (7%)
  • Continuous glucose monitoring/flash glucose monitoring targets: Time-in-range (3.9-10 mmol/L) >70% of time (or >50% in frail and older patients)
  • Hypoglycemia < 3.9 mmol/L (< 70 mg/dL): < 4% (< 1% in frail and older patients)

The panel advises stopping administration of metformin and sodium-glucose cotransporter–2 (SGLT2) inhibitors in patients with COVID-19 and type 2 diabetes in order to lower the risk of acute metabolic decompensation.

Fluid balance requires considerable care, “as there is a risk that excess fluid can exacerbate pulmonary edema in the severely inflamed lung.”

Potassium balance requires careful consideration in the context of insulin treatment, “as hypokalemia is a common feature in COVID-19,” with initiation of insulin possibly exacerbating it.

The panel recommends screening for hyperinflammation, owing to the possibility of increased risk for cytokine storm and severe COVID-19 in patients with type 2 diabetes and fatty liver disease.


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