COMMENTARY

Diabetes and COVID-19: Three Patient Cases

Anne L. Peters, MD

Disclosures

March 18, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

This transcript has been edited for clarity.

This is my second video on the coronavirus pandemic and how it affects people with diabetes. I will try to do these videos routinely as new information becomes available.

Let's first tell our patients not to panic. I know these are unsettling times, but everyone needs to put into perspective the fact that most people—both young and old—don't die from this disease. We all need to practice the principles we are being taught from the CDC and other credible sources to prevent the spread of the virus.

Does Diabetes Increase Risk?

We know far too little about the separate risk for people with diabetes. We all know that older people are at increased risk, particularly those with heart disease, but we don't know the additional risk that is conferred by having diabetes. In particular, we don't know the additional risk in a patient with well-controlled type 1 diabetes.

It is my personal opinion that my patients with well-controlled type 1 diabetes are not at increased risk for novel coronavirus infection. Or if they are, the increase in risk is small. I do know that managing type 1 diabetes during illness can be a challenge, and patients should be prepared with sick-day rules, as I discussed in my last video.

However, I don't think that my patients with well-controlled type 1 or type 2 diabetes are immunosuppressed. Cardiovascular disease and other complications may increase risk, but I tell my patients to simply follow all of the recommendations that are provided for everyone else.

'I Am Seeing What We Expect'

I'm going to tell you about three patients with diabetes who had COVID-19 infection. The first case, published in the Journal of Thoracic Imaging, describes a 23-year-old man in Wuhan who had presumed type 1 diabetes and a glycated hemoglobin level of 14%. He was quite ill, was hospitalized, and had extensive pulmonary disease but did not require intubation. Even with those very high glucose levels, he recovered.

The second case is a colleague's patient, a 77-year-old man with type 2 diabetes. His A1c levels have been in the high 7s. He has chronic kidney disease with an eGFR in the 40s, cardiovascular disease, and heart failure. He became ill very quickly with pulmonary symptoms. He was hospitalized and required intubation and dialysis, but has turned the corner and appears to be recovering. He received prompt, high-quality medical care. [Editor's note: This patient subsequently developed complications and has died.]

The final case is my patient, a 63-year-old man with well-controlled type 2 diabetes on semaglutide, empagliflozin, metformin, a statin, and an ARB. He had a stent in his LAD in the past but no recent cardiac issues. He developed symptoms of fever, cough, shortness of breath, and fatigue. He was tested and the results came back positive for the novel coronavirus.

I stopped his empagliflozin because he is fairly lean and I wanted to avoid any concerns about dehydration and diabetic ketoacidosis. He was hospitalized, but although he felt exhausted and slightly nauseated, his pulmonary symptoms did not worsen.

His blood glucose levels were tested four times daily while in the hospital. Interestingly, he did not have any elevations in his glucose levels. This was partly because he was eating less, but I was still surprised to see no obvious insulin resistance due to fever and illness. He has been discharged and is doing well, although I am holding his semaglutide for now until he's eating more normally.

So far, I am seeing what we expect—that most patients, even those at high risk, can be treated if the disease is recognized early and treatment is available. However, we know that we will lose some people to this virus no matter what we do, which is why people need to avoid exposure.

On another note, physicians and patients should recognize that not every bit of published information should change what we do. There have been some data suggesting that ACE inhibitors and ARBs may make people more vulnerable to novel coronavirus infection, which has patients concerned. In speaking to experts, this is not definitively clinically documented, and in all likelihood, these agents provide more benefit than harm.

I do not currently advise changing therapy for patients on these agents, although if more information becomes available, I will provide updates. My belief is that we can keep most of our patients with diabetes safe through this pandemic with kindness, comfort, and sound medical advice—and prompt, intensive care for patients who are seriously ill.

Anne L. Peters, MD, is a professor of medicine at the University of Southern California (USC) Keck School of Medicine and director of the USC clinical diabetes programs. She has published more than 200 articles, reviews, and abstracts and three books on diabetes, and has been an investigator for more than 40 research studies. She has spoken internationally at over 400 programs and serves on many committees of several professional organizations.

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