COMMENTARY

Not Just About Blood Sugar: 'He Died Because He Lost His Job'

Anne L. Peters, MD

Disclosures

May 15, 2020

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

This transcript has been edited for clarity.

This is another update on the coronavirus pandemic and how it affects people with diabetes.

First, in terms of most of the publications about diabetes and SARS-CoV-2, there are more and more studies describing hospitalized patients from around the world, and they show that diabetes is a risk factor for worse outcomes. We know that. But what really matters to me is whether I can do anything to mitigate the risk.

One study, published in Cell Metabolism, actually looked at glycemic control and its impact on outcomes. This was a retrospective analysis of patients with diabetes admitted to hospitals in Hubei Province, China. The authors included 7337 cases of COVID-19, of which 952 had preexisting type 2 diabetes. As others have found, those with diabetes required more procedures, had worse outcomes, and had a higher mortality than those without diabetes.

The people with diabetes were then divided into two groups: 282 people with well-controlled diabetes versus 528 whose disease was considered poorly controlled. They determined this in an unusual way. Designations of poorly controlled versus well controlled were made on the basis of A1c levels and what they call "glycemic variability." If glucose levels while in the hospital were between 70 and 180 mg/dL, they were considered well controlled, and glucose levels of 70 to > 180 mg/dL were considered poorly controlled. So, that upper end of the range was much higher.

The average A1c in the well-controlled group was 7.3%, and in the poorly controlled group it was 8.1%. The median blood glucose in the well-controlled group was 115 mg/dL, with a range of 94 to 135. In the poorly controlled group, the median glucose level was 196 mg/dL, with a range of 135 to 257. The authors presented lots of data, and they gave the raw data as well as data after propensity score matching.

However, when they looked at the data, nearly every parameter they assessed—from markers of inflammation to percent survival—was better in those who were well controlled. So, the well-controlled patients did significantly better than those who were poorly controlled.

I realize that there are many caveats in interpreting these data. It's not a randomized controlled trial; these are retrospective data obtained during a pandemic. But it does give me a reason to try to better control my patients' glucose levels during this period of time, both because I think it will help prevent them from having issues and it may help them do better if they are hospitalized.

Economic Pressures on Health Outcomes

Switching topics. Two months into this pandemic in the United States, economic pressures are playing a huge role in health outcomes. For example, the husband of a dear friend of mine, whom we've known for many years, lost his job because of the COVID-19 pandemic. He also lost his health insurance. He had diabetes and developed a nonhealing foot ulcer. He didn't go to a doctor because he had no insurance and was running out of money.

But it got worse, so he went to an emergency department. He was admitted and had a partial amputation of his great toe. Instead of being sent home, he was transferred to a rehab facility where he developed COVID-19. He quickly decompensated, was transferred back to the hospital, and died on a ventilator 4 days ago.

So, although he died of COVID-19, he also died because he had diabetes. But even more proximately, he died because he lost his job and access to healthcare.

As this pandemic continues, we will need to increasingly help people with diabetes get access to medications and the healthcare they need, even as they lose their jobs and their incomes.

How Can We Help?

There are a number of pharmaceutical and device companies that have created programs to help patients. However, most of these companies require that patients still obtain a prescription in order to get the medication and/or supplies.

As an example, I had a patient I was following in a research study, where her diabetes treatment was coming from her primary care provider and I simply monitored her glucose levels remotely. Then I tried to prescribe insulin for her from a pharmacy and pay with my credit card. The nearest pharmacy, which is a big-chain pharmacy, said that a vial of NPH insulin would cost $179. I then used GoodRx and found that I could get a vial of insulin for her for $28 with a coupon at a pharmacy that was reasonably close to her. But when I called, it turned out that pharmacies wouldn't take my credit card over the phone to pay for her insulin.

I thought one solution would be to try to have the pharmacy deliver her insulin through Instacart because I could use my credit card to order through Instacart. Although I could order other medications, it turns out that insulin can't be delivered by Instacart or other pharmacies because it has to be kept cold.

Finally, I got some samples from my own clinic and drove to find her. She lives in such a dangerous part of town—in an abandoned house—that she was afraid to come outside and meet me. I had managed to finally get her the insulin, and I left her a several-month supply. But as I drove off, I realized that she had no refrigeration, and it would have been much smarter to get her a 1-month supply at a time.

It was incredibly discouraging that I, supposedly a leading diabetes expert, couldn't manage to simply get one patient one vial of insulin that she needed to save her life. Unfortunately, I don't have easy answers. For many people, life has become much more difficult in all ways. I think solutions need to be local. In the case of my patient, after making sure she had enough insulin to survive, I set her up with our local resources that provide medical care and meals for the homeless. That is the best I can do. Hopefully, over time we can get her back into medical care for the assistance she needs.

As a general rule, we need to help our patients treat their diabetes within their capacity to afford medications—with metformin, sulfonylurea agents, and NPH and regular insulin as the least expensive options. Intermittent testing of blood glucose levels is helpful to look for extremes, but many will not be able to test routinely.

Overall, I've actually seen more issues with hypoglycemia than with hyperglycemia in my patients, so reductions in insulin and sulfonylurea doses may be needed based on food availability and increased levels of physical activity.

Finally, people need to be encouraged to seek medical care earlier rather than later, particularly for foot ulcers, infections, and symptoms of diabetes that is out of control. Additionally, the mental health piece here is huge; resources should be available to patients who are having issues dealing with this crisis.

Based on the article I discussed initially about glucose control and outcomes with COVID-19, it is important to do the best we can with all of our patients and all of their various life situations to control their diabetes, because I think we can help them do better.

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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